Humana's Your Practice

Eight Humana Policies You Should Know

Operating policies and procedures are designed to help Humana maintain an appropriate level of service to its members and network physicians. The following is a review of some of the key policies and procedures that impact network providers:

Adverse determinations/denial decision
If a member receives an adverse determination or denial, his or her attending physician or primary care physician may wish to discuss the decision with a Humana regional medical director or pharmacist reviewer. A peer-to-peer conversation may be scheduled by calling the local market office or by calling the number in the denial notification letter. In cases when another opinion may be needed, an External Review Organization (ERO) board-certified specialist may be consulted.

Clinical practice guidelines
Clinical practice guidelines are available on the provider area of Humana.com. Click on “Providers,” and then click on “Tools & Resources.” Select “Provider Tools,” then click on “Clinical & Health Care Resources.” Then select “Clinical Practice Guidelines,” and choose from the list of available clinical practice guidelines. The specific links take you from Humana’s Web site to the Web site of the organization that issued the guidelines. For example, the childhood immunizations link takes you to the Web site for the Centers for Disease Control and Prevention. Paper copies of the guidelines may also be requested from your local Humana market office.

Disease management (DM)
Humana offers several disease-specific programs to provide additional support to members and their physicians. These programs are designed to complement the physician’s treatment plan and empower the member through education and support. Information about available DM programs and procedures for accessing services are available on Humana’s Web site at Humana.com. Click on “Providers,” and then select “Health & Wellness” to see a list of links to specific DM programs.

Members’ rights and responsibilities
All commercial and Medicare Humana members have certain rights and responsibilities when being treated by Humana-contracted physicians. These rights are outlined in Humana’s Rights and Responsibilities statement. Physicians can find a copy of the statement in the provider manual. Humana asks participating physicians to display a copy of the Rights and Responsibilities statement in their offices. Provider manuals can be downloaded from Humana.com; from the provider home page, click on “Provider Manuals” listed under “Quick Links” on the right.

Medical record audits
To facilitate thorough record keeping, Humana regularly conducts medical record audits in randomly selected physician offices. The minimum passing score is 85 percent with a goal of 90 percent. Medical records should comply with The National Committee for Quality Assurance (NCQA) and Medicaid Managed Care Quality Assurance Reform Initiative (QARI) guidelines for medical records documentation; these guidelines are detailed in Chapter 13 of the National Health Service Corps Site Development Manual. To view these guidelines, visit the National Health Service Corps Web site at http://nhsc.bhpr.hrsa.gov/resources/SRM-toc.asp or call your local Humana market office to request a paper copy.

Quality improvement (QI) program
Humana has a comprehensive quality improvement program that encompasses clinical care, preventive care and administrative functions of the health plan. Physicians may obtain a written QI program description by contacting Humana customer service at 1-800-4-HUMANA (1-800-448-6262). For a progress report of how goals are being met in individual markets, mail a request to the following address:

Quality Management Department - QI Progress Report
321 W Main St., WFP 20
Louisville, KY 40202

Urgent/emergent services
Humana 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 as long as the member perceives an emergency situation exists according to 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 urgent or emergency visits.

Utilization management (UM)
The utilization management program helps guide members toward appropriate physician recommended treatment options. It is important that physicians, other health care providers and Humana members know the following about the program:

Humana uses nationally recognized guidelines for all utilization review and coverage determinations.
Humana does not reward health care providers for denying service or care
Financial incentives are not part of a UM decision.
Physicians can obtain a copy of specific UM criteria from their local market office upon request.

Humana continually reviews its policies and procedures and updates them as necessary. Any changes to these and other policies and procedures will be communicated to members and network providers.