Claims Processing Edits
The new edits will check for the presence or absence of specific medical procedure codes reported at the claim level for inpatient or outpatient hospital services.
More About Our Edits
These edits are being added in order to comply with the final Health Insurance Portability and Accountability Act (HIPAA) rule, which named the ICD-9-CM Volume 3 Procedure Codes (including The Official ICD-9-CM Guidelines for Coding and Reporting) as the HIPAA standard medical code set for inpatient hospital services, and the HCPCS/CPT codes as the HIPAA standard medical code set for physician services and other health care services (including outpatient hospital procedures). With the implementation of these edits, Humana will:
- No longer accept outpatient hospital claims with ICD-9-CM Vol 3 procedure codes in either or both the Procedure Information segment (BQ) or Other Procedure Information (BR). Humana will follow the HIPAA standard medical code set of HCPCS/CPT codes for outpatient services. Humana's rejection message will state, "ICD-9 valid only for hospital inpatient bill types."
- No longer accept an inpatient hospital claim with a HCPCS/CPT code in either or both the Procedure Information segment (BP) or Other Procedure Information (BO). Humana's rejection message will state, "ICD-9 must be used for hospital inpatient reporting."
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April 24, 2010, Claim Code Edits
View a list of modifications to Humana’s claims payment policies that support Humana’s continuing efforts to process claims fairly, accurately and appropriately. We're updating our claim code-editing logic in several areas of the American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, 9th Edition/Revision (ICD-9) code sets.
- All markets (excluding Puerto Rico)
- (84 KB) Download PDF
- English
- January 24, 2010 Claim Code Edits
- View a list of modifications to Humana’s claim payment policies to support our continuing efforts to process claims fairly, accurately and appropriately. We are updating our claim code-editing logic in several areas associated with the American Medical Association (AMA) Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, 9th Edition/Revision (ICD-9) code sets.
Additional enhancements allow Humana to apply coverage determinations specifically by region, which will facilitate current and consistent application of NCDs/LCDs in claim adjudication. - (40 KB) Download PDF
- English
- January 24, 2010 – No Benefit Codes – Commercial and Medicare products
- View lists of codes for services that will not be covered effective January 24, 2010.
- Commercial
- (74 KB) Download PDF
- English
- Medicare HMO
- (65 KB) Download PDF
- English
- Medicare PPO
- (58 KB) Download PDF
- English
- Medicare PFFS
- (56 KB) Download PDF
- English
- October 27, 2009 Claim Code Edits
- View a list of modifications to Humana’s claims payment policies that support Humana's continuing efforts to process claims fairly, accurately and appropriately. We’re updating our claim code-editing logic in several areas of the American Medical Association (AMA) Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, 9th Edition/Revision (ICD-9) code sets.
- (17.9 KB) Download PDF
- English
- June 30, 2009, Claim Code Edits
- View a list of modifications to Humana's orthotic, prosthetic and durable medical equipment claims payment policies to reflect nationally and regionally accepted standards, including the following:
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- National and regional Centers for Medicare & Medicaid Services (CMS) coverage decisions
- Durable Medical Equipment Medicare Administrative Contractor (DME MAC) manual
- Healthcare Common Procedure Coding System (HCPCS) definitions
- Appropriate modifier usage (e.g., anatomic modifiers, functional modifiers, etc.)
- (44 KB) Download DOC
- English | Spanish
- November 29, 2008, Claim Code Edits
- View a list of updates to Humana's claim code-editing software that affects several areas of the American Medical Association (AMA) Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, 9th Edition/Revision (ICD-9) code sets.
- (44 KB) Download DOC
- English
- Significant Edits
- View a list of edits that affect at least 500 claims per year and differ from AMA CPT or CCI coding guidelines.
- (20.2 KB) Download PDF
- English
- Modifier 59 Edits
- View a list of code combinations that Humana has determined are not appropriately reported together with a modifier 59 and which differ from AMA CPT coding guidelines.
- (17.9 KB) Download PDF
- English
