What's New

Here are our newest tools and resources available to our Providers.

Reminder: January 24, 2010 Claim Code Edits for Medicare Advantage Providers

Last October, we mailed written notifications to providers that we will be enhancing our claim editing logic to automate the application of national coverage determinations (NCDs) and local coverage determinations (LCDs) effective January 24, 2010. This new enhancement allows Humana to apply coverage determinations specifically by region, which will facilitate current and consistent application of NCDs/LCDs in claim adjudication. Find more information below.

Updating Details: (40 KB) Download PDF; English

DeductibleFirst PCA

A new Humana health plan, DeductibleFirst Personal Care Account (PCA), effective Jan. 1, 2010, is designed to pay physicians and other health care providers directly and help members become more involved in the management of their health care choices.

Unlike other PCA-type plans, when a provider files a claim for a DeductibleFirst PCA-covered patient, Humana will process the claim to determine the amount to apply to the patient’s deductible. After the deductible has been met, those expenses that are eligible to be paid by the PCA are determined and Humana will make payment directly to the provider. This will allow one check to be mailed to the provider representing PCA funds and coinsurance amounts the plan is paying, making reimbursement easier for the provider and the patient. This is how it works:

At the beginning of the plan year, claims are paid from the deductible portion of a member’s plan before the PCA funds are used
When the deductible has been met, PCA funds are used to pay claims
Claims payments from PCA funds are paid directly to the provider
When PCA funds are exhausted, the member is then responsible for any remaining deductible (if applicable), coinsurance and/or copayments

With this new plan, a HumanaAccess® Visa® Debit Card will not be needed. The PCA will fund only amounts that are applied to in-network participating deductibles.

DeductibleFirst is available in eight markets (Illinois, Indiana, Kansas, Kentucky, Michigan, Missouri, Ohio and Wisconsin). Additional markets may be added later.

For more information, please click the link below to view frequently asked questions, or contact customer service at 1-866-4ASSIST (1-866-427-7478).

Frequently Asked Questions: New DeductibleFirst Personal Care Account: (31 KB) Download PDF; English

2010 Medicare Drug List Changes

Effective January 1, 2010, certain drugs will no longer be covered or will have new limitations under Humana’s Medicare formularies for the 2010 plan year.

These changes could mean higher costs, new limitations or requirements for Humana members who choose to continue to use the impacted medications. Humana encourages the use of generic and cost-effective brand medications whenever possible.

Below is a chart that shows the most commonly used drugs that will be affected by Humana’s 2010 formulary changes, along with possible alternatives. Please note that drug coverage changes may vary between formularies.

Humana 2010 Medicare Drug List Changes: (66 KB) Download PDF; English

H1N1 Vaccine Guidance

The new H1N1 influenza virus has the potential to have serious health consequences for our country, and clinicians will be on the front line of the epidemic. Humana has compiled information that may be useful for physicians and office personnel:

The federal government is the sole purchaser of the novel H1N1 vaccine. It will manage the funding and distribution of the novel H1N1 vaccine. Humana will cover H1N1 vaccine administration as follows:

1. Question: What is Humana’s coverage guidance for the H1N1 vaccine?

Commercial Fully Insured – H1N1 vaccine administration will be fully covered for fully insured members.
HumanaOne^® – H1N1 vaccine will be fully covered for HumanaOne members.
Administrative Services Only (ASO) – Individual groups provide Humana direction about coverage.
Medicare – Most Medicare members have access to flu shots under their Medicare Advantage Prescription Drug (MAPD) Part B benefit. Humana Medicare members with Part D-only coverage will not have coverage for H1N1 vaccine administration with their Humana benefit. Claims for H1N1 administration submitted for Humana Part D-only members will result in a denied claim.
Nonparticipating providers – Nonpar providers will be reimbursed for administration of the H1N1 vaccine.

2. Question: What codes should be used for H1N1 vaccine administration?

Answer: Physician offices and other providers should use either CPT 90470 or G9141.

3. Question: Should providers submit codes such as CPT 90663 or G9142 for the vaccine itself?

Answer: No. The federal government provides the vaccine free; therefore, Humana will deny codes submitted for the vaccine.

4. Question: Is there a quantity limit?

Answer: No. Adults need only one H1N1 immunization, but children 10 and under will require two doses. For that reason, quantity limits have not been implemented.

5. Question: Is there an age limit?

Answer: Children under the age of 6 months should not receive the vaccine; however, there is no upper age limit for vaccination recommendations.

6. Question: Can I charge a copayment to my Humana-covered patient?

Answer: If the only service provided to the member that day is H1N1 immunization, then a copayment would not be allowed. However, if there are other services for which copayment is typically required, the copayment may be collected.

Health care providers with questions about Humana’s policies for H1N1 coding or coverage may call provider relations at 1-800-626-2741.

The CDC offers excellent information regarding screening and managing patients, vaccine resources and patient education. For the most up-to-date information, please refer to the CDC clinician Web site: www.cdc.gov/h1n1flu/clinicians

Health care providers interested in administering the H1N1 vaccine will need to preregister with their local health department. Local contact information may be found on the CDC Web site: www.cdc.gov/h1n1flu/vaccination/statecontacts.htm

EFT Format

Beginning in October 2009, EFT payment transactions will be reported with a new file format (CCD+), which is the recommended industry standard for EFT payments. The CCD+ format is a National Automated Clearing House Association (NACHA) ACH corporate payment format with a single 80 character addendum record capability. The addendum record is used by the originator to provide additional information to the payment recipient about the payment. The new format will also be referenced in the ERA (835 data file).

Improved Referral and Authorization Tool

There are some exciting new changes about to take place on the Humana.com authorization and referral system. These changes will provide a faster and more effective way to submit inpatient and outpatient referrals and authorization requests. These enhancements are based on feedback from Humana's health care providers.

By submitting authorization and referral requests via the Web, you will be able to take advantage of easier transactions and faster response times. You also will be able to take advantage of these new enhancements:

Submit your requests using our new single-page design for faster, easier entry
Save time by checking if an outpatient authorization is required before the online submission is completed
Use our new provider search tools to receive more usable provider information
Create your own favorites lists (service types, procedures, and diagnosis codes) for fast data entry
Use the new quick-print feature and place copies of referral and authorization documents in the patient's chart or send them to the "referred to" provider
Receive a quick response. Many requests for authorizations and referrals are approved right on the spot.

Coming Soon: A quick Tour of Our New Referral and Authorization Tool: Take a quick tour of the improved tool.; (788 KB) Download PDF; English

ERA/EFT Registration Redesigned

In early September, Humana began automating the Electronic Remittance Advice (ERA)/Electronic Funds Transfer (EFT) set up and maintenance process. This new enhancement will increase efficiency, reduce errors and improve processing times for enrollment and changes.

The enhancement will allow providers to perform the following actions online:

Add ERA/EFT, ERA, EFT
Cancel ERA/EFT, ERA, EFT
Move to Production, Change to Test, Extend Test, Confirm Pre-note, Update Bank Information
Vendor Change, Status Inquiry

Claims vendors, such as clearinghouses and billing agencies, can take the following actions online:

Add ERA/EFT,Add ERA, Status Inquiry
Vendor Reporting

Improved Provider Remittance Inquiry Tool

The Provider Remittance Inquiry has undergone some exciting new changes, to streamline the interface and improve the tool. All of the previously available functionality will remain, along with the following enhancements:

Single Remit Download now includes a PDF option. Now providers can view and print a PDF version of their Explanation of Remittance (EOR) files. This option is in addition to the previous options to download 835 format, Word and Excel versions of their files.
Explanation of Remittance Downloads page. Providers can track all EOR files that they have chosen to download and view their download status. Files display status as “running” during download and will change to “available” once they are complete. All files selected for download will be accessible for 24 hours.
Streamlined Details Views. All of the detail functions have been classified into expandable categories, which allow providers to customize the display to view only the information they need.
The enhanced Humana Remittance Review now includes a new Help feature that contains frequently requested help documentation specific to the Remittance Review function.

Log onto Humana.com to take advantage of these new features.

Cariten Transition

In November 2008, Cariten Healthcare a Knoxville, TN based healthplan became a part of the Humana family. For the most current information regarding the integration of Humana/Cariten Healthcare visit the Cariten Provider Transition Page at Cariten.com

Advanced Illness Planning

Humana's Advanced Illness Planning program is designed to help providers utilize resources to improve outcomes associated with better symptom management and quality of life as well as provide guidance and support to members and caregivers concerning all forms of an advanced illness.

One of the resources available to providers is this link to The Robert Wood Johnson Foundation (RWJF). The foundation and its grantees produce research and data about complex health and health care issues in the United States. One of those issues is end-of-life or palliative care. Despite advances in medical care, Americans often still suffer from unnecessary pain, discomfort and lack of caring at the end of life. RWJF offers providers information on a wide variety of topics through access to publications, journal articles, public policies and Web resources. Topics range from the status of medical education in end-of-life care to best practices, pain management and hospice care in nursing homes.

The Pet Prescription

Evidence is mounting in support of a "pet prescription" for the therapeutic value of animals. Their roles have expanded beyond those of guide animals to those that provide therapy to people with a variety of needs from helping children with Autism to detecting when a person is going to have a seizure. Today, dogs also are providing emotional services.

Laws vary by state. The phrase "therapy dogs" often indicates dogs that may or may not be used for emotional service. In some states, emotional service dogs do not have the same rights as assistance or therapy dogs. That means letters provided by physicians to substantiate the need for an emotional support animal or for a therapy animal should be specific to their patient's need for animal support.

There is increasing awareness on this topic, as well as additional available information. One site offering such information is www.petsincondos.org

Get paid by the top payer

According to PayerView^SM, an annual ranking of health benefits companies conducted by athenahealth® and Physicians Practice magazine, Humana:

Paid providers fastest
Denied fewest claims
Had a 99 percent claim accuracy rate
Paid nearly 96 percent of claims upon first submission

Humana continues to provide new ways to simplify administrative processes, make transactions more transparent, and advance multipayer solutions through technologies such as real-time adjudication (RTA) and Availity.com, the multipayer provider portal. To find out how you can benefit, return to Humana.com/providers and look around our provider Web site.

PayerView ranks health insurers according to financial and administrative performance and medical policy complexity. Athenahealth is a medical service and software company. Physicians Practice is a medical practice management journal.

To see the Payerview Rankings, visit www.athenahealth.com/payerview

PayView Ad: (645 KB) Download PDF; English

Bruce Perkins speaks about the Payer View ranking.

Humana at the very top of its 2009 "easiest payer to do business with" list.

WMV (5.9 MB) – English
Runtime 3 min, 14 sec

Provider Notice

Influenza Pandemic Emergency: (2.4 KB) Download PDF; English

Preterm Delivery Prevention Program

A preterm delivery prevention program for pregnant women with a history of spontaneous preterm birth at less than 37 weeks of gestation

Program Details: (0.3 MB) Download PDF; English

Preview the New look of the Provider Self-Service Center

Effective December 13, 2008, the look of the provider self-service center will change.

(3.48 MB) Download PPT

English

Texas Deficiency Tool

Texas-based providers can learn how to check their deficient claims online by clicking here.

CMS Preventable Conditions National Quality Forum Never Events

Learn more about Humana's policy.

Real Time Claims Adjudication (RTCA)

This capability allows a provider to bill for services at the "point of service." A fully adjudicated response is returned from Humana, detailing the total charge submitted, allowable charges, as well as the patient's responsibility.

Provider Medicare Information

Obtain more information about plans offered in your area.

Meals on Wheels

Learn more about services that can benefit your patients with Humana plans.

Web Based Training and Demo

Humana.com users can now use this Demo to help guide them through functionality on Humana.com.

Paymentech

Humana is pleased to introduce a new program created exclusively for Humana and Humana ChoiceCare Network participating providers that is designed to help reduce credit card transaction fee costs for your practice. Through this new program, created by a Humana and Chase Paymentech Solutions, LLC partnership, your practice can accept credit cards at significantly discounted processing rates.

National Provider Identifier (NPI)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that all providers use a standard unique identifier on all standard electronic transactions. The use of the National Provider Identifier (NPI) is mandated on all HIPAA-standard electronic transactions by May 23, 2007.

Explore Provider Self-Service Center

Business Function Realignment - Humana.com Primary Access Administrators will now find it easier to give their associates access to secured business functionality. These functions within the “Administration” area are now listed in a more user friendly format.
How to access and login to Secure Portal, Select Assign Web Access Rights in the Administration Panel
How to link from Secure Portal to the Provider Resource Center – Humana.com users will now have the capability to access the Provider Resource Center from their secure menu, without logging out of the secure portal.
How to Access: Login to the Secure Portal, the link will appear in the Information Center Panel

False Claims

It is a federal requirement that Medicaid-contracted medical providers and their employees adopt "Humana's Business Entity and Employee Education Policy about False Claims Recovery."

Humana Business Entity and Employee Education Policy about False Claims Recovery - Florida: (40 KB) Download PDF; English
Humana Business Entity and Employee Education Policy about False Claims Recovery - Puerto Rico: (36 KB) Download PDF; English