Procedures requiring
medical-record review
The following list contains procedures or services that may require the submission of member medical records for 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)
This is not an all-inclusive list. There may be additional occasions when medical records will be requested to validate a claim or coverage.
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.
Please 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:
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.
Please direct all medical records to the following address:
Humana
P.O. Box 14601
Lexington, KY 40512-4601
If you have any questions about this information, please call 1-800-4HUMANA (1-800-448-6262).
This above listing of procedures and services is subject to change and may be updated in the future.
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