Procedures or services that may require medical record review
- Any service submitted with a procedure code that is not specific
- Nonsurgical obesity services
- Services related to growth hormone therapy
- Pre-existing conditions
- Physical therapy, speech therapy, occupational therapy (upon request)
- Chiropractic services (upon request)
- Cognitive therapy and sensory integration
- Low vision rehabilitation
- Alternative medicine and related services (upon request)
- Investigational/experimental procedures, drugs, devices, other supplies or services (Phase I, Phase II, Phase III, and emerging/evolving technology or procedures)
- Dental or oral maxillofacial services or procedures when submitted for coverage under a medical plan
- Services related to patient management, coordination of care, crisis intervention, multidisciplinary assessment, or other unique community/member support/therapy services
- Services for which diagnosis and procedure do not match (upon request)
- Musculoskeletal services (upon request)
- Any service submitted with a modifier 22 appended
- Request for reconsideration of a previously denied claim when pre-authorization was required but for which no pre-authorization is currently on file
- Air ambulance services
- Medicare risk adjustment activities
- Special investigations
- Quality improvement activities
- HEDIS data collection
- Emergency room services
- Infertility related services
- Bariatric surgery
- Transplant services
- IV infused medications
- Amniotic membrane transplantation
- Capsule endoscopy
- Any service submitted with a modifier 66 appended
- Autism related services
- Prosthetic devices and services
- Spinal Fusion
- Collection of missing diagnosis data
- Verification of reported HCC diagnosis codes
- Response to CMS Risk Adjustment Data Validation (RADV) reviews and audit
- MOD A and MOD B services
This is not an all-inclusive list. There may be additional occasions when medical records will be requested to validate a claim or coverage.
Medical record submission
Physicians who want to submit medical records with a claim may use the above list as a guide. If medical records are not received, they will be requested at the time claims are received. There may be an associated delay in claims payments.
Note: The need to submit medical records may be dependent on the member's plan. Since not all plans have the same requirements or coverage, the provider may elect to contact Humana. Additional information is available in the following areas:
Describes the evaluation and coverage of medical procedures and devices that are being investigated or have been recently introduced.
Utilization management may be performed by contracted vendors, and they may also request medical records for review, based on the member's plan. If the vendor issues a utilization management decision, it will be honored by Humana, and no further records will be requested. If the vendor's request for medical records is not honored, the claim may not be paid.
The submission of medical records is not a guarantee of payment. All plan provisions still apply and services not covered by the member's plan will not be paid. Unless otherwise instructed, please direct all medical records to the following address:
HumanaP.O. Box 14601Lexington, KY 40512-4601
If you have any questions about this information, please call 1-800-4HUMANA (1-800-448-6262).
The above list of procedures and services is subject to change and may be updated in the future.