Utilization Management Program Facts

The utilization management (UM) program plays a key role in fulfilling Humana’s vision. It is important that physicians, other health care providers and their patients understand these facts:

• Decisions regarding UM are based only upon the appropriateness of care and service and the existence of coverage.
• Humana does not reward health care providers for issuing denials of coverage or service care.
• Financial incentives are never part of a UM decision.

Humana uses nationally recognized clinical criteria as guidelines for all utilization review determinations. These guidelines are available on the provider area on Humana’s Web site at www.humana.com. Just click on “Providers” on the left side of the page, and then go to the “Patient Care Tools and Services” page. Then click on “Clinical Practice Information.” You can then choose from “Childhood Immunizations, Diabetes Care, Heart Failure, Asthma Care, Atherosclerotic Cardiovascular Disease or Preventive Care.” Paper copies of the guidelines may also be requested from the local market office.

The attending physician or primary care physician (PCP) has the opportunity to have a peer-to-peer conversation with a Humana medical director or pharmacist reviewer to discuss a possible adverse determination or a denial decision. These conversations can be scheduled by calling the local market office or by calling the number given in the denial notification letter. In cases when another opinion may be needed, an External Review Organization (ERO) board-certified specialist may be asked to review the case.

Covered members have access to urgent/emergent services for screening and stabilization 24 hours a day, seven days a week, in- or out-of-the-service area if the member perceives that an emergency situation exists per the “prudent layperson” standard. This means that a person with average knowledge of health services and medicine, acting reasonably, would have believed an emergency existed. No referral or authorization is required for emergency visits.

Humana also has a comprehensive Quality Improvement (QI) program. A written QI program description is available upon request by contacting Humana Customer Service at 1-800-4-HUMANA (1-800-448-6262) or by contacting the local health plan.

Please take every opportunity to share this information with your patients and staff to help them understand the process of utilization review.

Back to top