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Financial Recovery Clinical Audit Appeals Policy for Health care Providers

Below you will find a description of the Financial Recovery Clinical Audit Appeal Process for Health care Providers. Health care Providers have the right to appeal the results of audits performed by Humana or Humana's third-party vendors at three levels of review. Please note that Humana's third-party vendors have executed Business Associate Agreements with Humana and follow Health Insurance Portability and Accountability Act (HIPAA) guidelines.

Level 1 Appeals:

Once an original claim determination is made, all Health care Providers have the right to appeal. All level 1 appeals are returned to the original reviewing organization. The following is an overview of the level 1 appeals process:

  • Health care Provider receives the initial audit findings letter
  • Health care Provider has 30 calendar days from the date of the initial audit findings letter to request a level 1 appeal by the original reviewing organization before the findings are submitted to Humana and overpayments are requested. Recoupment may occur after the initial 30-calendar-day time period. Appeals should be sent to the address listed on the letter explaining the findings and appeal address for the case.
  • Health care Provider may be submitted a level 1 appeal up to 120 calendar days from the date of the findings letter
  • The address/fax number for appeal submission is included in each finding letter
  • All requests for an appeal must be in writing
  • Health care Provider may send the additional medical records or documentation to support billing to the level 1 appeal address listed on the initial findings letter.
  • Claim will be reviewed by licensed personnel appropriate for the audit type (Professional Coder, physician, Registered Nurse, or Pharmacist, etc) who are different from the personnel who made the initial determination.
  • Provider will receive a level 1 outcome letter from the level 1 appeal review within 60 calendar days of receipt of the appeal and/or additional documentation.
  • When the level 1 appeal is received, the offset will be placed on hold (if not already collected) so that monies are not recouped or offset from future payment until the appeal is resolved.
  • Reasonable extensions will be granted

Level 2 Appeals:

Level 2 appeals are reviewed by a third-party vendor that does not conduct the initial claim for Humana. The third party vendor conducts similar audits for the Centers for Medicare & Medicaid Services (CMS) in the Recovery Audit Contractor Program (RAC). The following is an overview of the level 2 appeals process:

  • Health care Provider can respond to the level 1 finding outcome letter and request a level 2 appeal
  • Health care Provider may be submitted a Level 2 appeal up to 120 calendar days from the date of the Level 1 Outcome
  • All requests for an appeal must be in writing
  • Health care Provider may send any additional medical records or documentation to support billing that had not been submitted previously
  • Level 2 appeal requests are sent to the Humana Clinical Audit Appeals Team at the following address:
    Humana Financial Recovery Clinical Audit Appeals
    PO Box 14279
    Lexington, KY 40512-4279
    Fax 888.815.8912
  • Level 2 appeals are received by Humana and sent to a third-party vendor
  • When the level 2 appeal is received, the offset will be placed on hold (if not already collected) so that monies are not recouped or offset from future payment until the appeal is resolved
  • There are no monetary limits at this level of appeal
  • Third-party reviewing company will send a level 2 outcome letter from the level 2 appeal review within 60 calendar days of receipt of the appeal and/or additional documentation to the health care provider and Humana
  • Reasonable extensions will be granted

Level 3 Appeals:

Level 3 Appeals are reviewed by Humana. The Internal Clinical Physician Review team or the Internal Coding team will conduct the review depending on the type of audit and expertise required. A physician will review all medical necessity cases. The following is an overview of the level 3 appeals process:

  • Health care Provider can respond to the level 2 finding outcome letter and request a level 3 appeal
  • Health care Provider may be submitted a Level 3 appeal up to 120 calendar days from the date of the Level 2 Outcome
  • All requests for an appeal must be in writing
  • Health care Provider may send any additional medical records or documentation to support billing that had not been submitted previously
  • Third level appeal requests are sent to the Humana Clinical Audit Appeals Team at the following address:
    Humana Financial Recovery Clinical Audit Appeals
    PO Box 14279
    Lexington, KY 40512-4279
    Fax 888.815.8912
  • When the level 3 appeal is received, the offset will be placed on hold (if not already collected) so that monies are not recouped or offset from future payment until the appeal is resolved
  • Level 3 outcome letter is sent by Humana within 60 calendar days of receipt of the level 3 appeal and notice and/or additional documentation to the Health care Provider
  • Reasonable extensions will be granted

Humana will follow all federal and state laws and regulations. Where more than one state is impacted by a particular issue, to allow for consistency, Humana follows the most stringent requirement. This standard is subject to change or termination by Humana at any time. Humana has full and final discretionary authority for its interpretation and application. This standard supersedes all other Humana policies, standards or information conflicting with it.