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1. Introduction

Humana Gold Choice® and Humana Medicare Employer PFFS are Medicare Advantage private fee-for-service (PFFS) plans offered by Humana. Humana Medicare Employer PFFS allows members to use any provider, such as a physician, health professional, hospital, or other Medicare provider in the United States that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B (also known as ‘Original Medicare’) or eligible to be paid by Humana Gold Choice and Humana Medicare Employer PFFS for benefits that are not covered under Original Medicare.

The law provides that if you have an opportunity to review these terms and conditions of payment and you treat a Humana Gold Choice or a Humana Medicare Employer PFFS member, you will be “deemed” to have a contract with us. Section 2 explains how the deeming process works. The rest of this document contains the contract that the law allows us to deem to hold between you, the provider, and Humana. Any provider in the United States that meets the deeming criteria in Section 2 becomes deemed to have a contract with Humana for the services furnished to the member when the deeming conditions are met. No prior authorization, prior notification, or referral is required as a condition of coverage when medically necessary, plan-covered services are furnished to a member. However, a member or provider may request an advance organization determination before a service is provided in order to confirm that the service is medically necessary and will be covered by the plan. Note that the terms prior authorization, prior notification, and advance organization determination have different meanings. Section 7 describes how a provider can request an advance organization determination from the plan.

Humana has signed contracts with some providers. These providers are our network providers.

Humana has network providers for all Medicare Part A and Part B services.

Humana Gold Choice and Humana Medicare Employer PFFS have network providers for durable medical equipment (DME), home health, laboratories and hospitals in specific areas.

Our members can still receive services from non-network providers who do not have a signed contract with us, as long as the provider meets the deeming criteria described in Section 2. These deemed contracting providers are subject to all of the terms and conditions of payment described in this document. The list of network providers can be accessed on Humana.com via the provider directory.

The amount of cost-sharing a member pays a provider who is not one of our network providers may be more than the cost-sharing the member pays a network provider. Humana indicates the services for which the cost-sharing amount differs between full and partial network providers and non-network providers in the Humana Gold Choice and Humana Medicare Employer PFFS Member Evidence of Coverage (EOC).

2. When a provider is deemed to accept Humana Medicare Advantage PFFS terms and conditions of payment

A provider is deemed by law to have a contract with Humana when all of the following three criteria are met:

  1. The provider is aware, in advance of furnishing health care services, that the patient is a member of Humana Gold Choice or Humana Medicare Employer PFFS. All of our members receive a member ID card that includes the Humana Gold Choice or Humana Medicare Employer PFFS logo that clearly identifies them as PFFS members. The provider may validate eligibility by calling our member/provider service number on the member’s identification card or online at Humana.com.
  2. The provider either has a copy of, or has reasonable access to, our terms and conditions of payment (this document). The terms and conditions are available on our website at Humana.com. The terms and conditions may also be obtained by calling our Humana provider relations department at 1-866-291-9714.
  3. The provider furnishes covered services to a Humana Gold Choice or Humana Medicare Employer PFFS member.

If all of these conditions are met, the provider is deemed to have agreed to Humana Medicare Advantage PFFS terms and conditions of payment for that member specific to that visit. For example: If a Humana Gold Choice or Humana Medicare Employer PFFS member shows you an enrollment card identifying him/her as a member of Humana Gold Choice or Humana Medicare Employer PFFS and you provide services to that member, you will be considered a deemed provider. Therefore, it is your responsibility to obtain and review the terms and conditions of payment prior to providing services, except in the case of emergency services (see below).

NOTE: You, the provider, can decide whether or not to accept Humana Medicare Advantage PFFS terms and conditions of payment each time you see a Humana Gold Choice or Humana Medicare Employer PFFS member. A decision to treat one plan member does not obligate you to treat other Humana Gold Choice or Humana Medicare Employer PFFS members, nor does it obligate you to accept the same member for treatment at a subsequent visit.

If you DO NOT wish to accept Humana Medicare Advantage PFFS plans terms and conditions of payment, then you should not furnish services to a Humana Gold Choice or Humana Medicare Employer PFFS member, except for emergency services. If you nonetheless do furnish non-emergency services, you will be subject to these terms and conditions whether you wish to agree to them or not. Providers furnishing emergency services will be treated as non-contracting providers and paid at the payment amounts they would have received under Original Medicare.

3. Provider qualifications and requirements

In order to be paid by Humana for services provided to one of our members, you must:

  • Have a National Provider Identifier in order to submit electronic transactions to Humana, in accordance with HIPAA requirements.
  • Submit your claims electronically whenever possible. For non-electronic transactions, submit claims using the standard CMS-1500, CMS-1450, and/or UB-04, or their successors. Refer to Section 5, Filing a Claim for Payment for more details.
  • Be licensed or certified by the state and furnish services to a Humana Gold Choice or Humana Medicare Employer PFFS member within the scope of your licensure or certification.
  • Provide only services that are covered by our plan and that are medically necessary by Medicare definitions.
  • Meet applicable Medicare certification requirements (e.g., if you are an institutional provider such as a hospital or skilled nursing facility).
  • Not have opted out of participation in the Medicare program under §1802(b) of the Social Security Act, unless providing emergency or urgently needed services.
  • Not be on the Health and Human Services (HHS) Office of Inspectors General excluded and sanctioned provider lists.
  • Not be a Federal health care provider, such as a Veterans’ Administration provider, except when providing emergency care.
  • Comply with all applicable Medicare and other applicable Federal health care program laws, regulations, and program instructions, including laws protecting patient privacy rights and HIPAA that apply to covered services furnished to members.
  • Agree to cooperate with Humana to resolve any member grievance involving the provider within the time frame required under Federal law.
  • For providers who are hospitals, home health agencies, skilled nursing facilities, or comprehensive outpatient rehabilitation facilities, provide applicable beneficiary appeals notices (See Section 10 for specific requirements).
  • Not charge the member in excess of cost-sharing under any condition, including in the event of plan bankruptcy
  • Be a Medicare-certified provider for supplemental services.

4. Payment to providers

Plan payment

Humana reimburses deemed providers at the amounts they would have received as participating or nonparticipating physicians, as applicable, under Original Medicare. This includes applicable rates and expectations for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) subject to Original Medicare’s DMEPOS Competitive Bidding Program and National Mail-order Competition rules for Medicare-covered services minus any member required cost-sharing, for all medically necessary services. In addition, settlement for certain payment methodologies is available upon request. Humana will pay Physician Quality Reporting Initiative (PQRI) bonus and e-prescribing incentive payment amounts to deemed physicians who would receive them in connection with treating Medicare beneficiaries who are not enrolled in a Medicare Advantage plan.

We will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, then we will pay interest on the claim according to Medicare guidelines. Section 5 has more information on prompt payment rules. Payment to providers for which Medicare does not have a publicly published rate will be based on the estimated Medicare amount. For more detailed information about our payment methodology for all provider types, please contact us at the member/provider service number listed on the back of the member’s identification card.

Services covered under Humana Gold Choice or Humana Medicare Employer PFFS that are not covered under Original Medicare are reimbursed using a fee schedule or funds allocated to members based on the type of services provided. Please call us at the member/provider service number listed on the back of the member’s identification card to receive information on the reimbursement.

Deemed providers furnishing such services must accept the fee schedule amount, minus applicable member cost-sharing, as payment in full.

Member benefits and cost-sharing

Payment of cost-sharing amounts is the responsibility of the member. Providers should collect the applicable cost-sharing from the member at the time of the service when possible. You can only collect from the member the appropriate Humana Gold Choice or Humana Medicare Employer PFFS copayments or coinsurance amounts described in these terms and conditions. After collecting cost-sharing from the member, the provider should bill Humana for covered services. Section 5 provides instructions on how to submit claims to us. Please note, however, that Humana may not hold members accountable for any cost-sharing (deductibles, copayments, coinsurance) for Medicare-covered preventive services that are subject to zero cost-sharing.

If a member is a dual-eligible Medicare beneficiary (that is, the member is enrolled in our PFFS plan and a State Medicaid program), then the provider cannot collect any cost- sharing for Medicare Part A and Part B services from the member at the time of service when the State is responsible for paying such amounts (nominal copayments authorized under the Medicaid State plan may be collected). Instead, the provider may only accept the MA plan payment (plus any Medicaid copayment amounts) as payment in full or bill the appropriate State source.

To view a complete list of covered services and member cost-sharing amounts under Humana Gold Choice or Humana Medicare Employer PFFS, go to Humana.com/providers. You may call us at the member/provider service number listed on the back of the member’s identification card to obtain more information about covered benefits, plan payment rates, and member cost-sharing amounts under Humana Gold Choice or Humana Medicare Employer PFFS. Be sure to have the member’s ID number when you call.

Humana Gold Choice and Humana Medicare Employer PFFS follow Medicare coverage decisions for Medicare-covered services. Services not covered by Medicare are not covered by Humana Gold Choice or Humana Medicare Employer PFFS, unless specified by the plan. Information on obtaining an advance coverage determination can be found in Section

7. Humana Gold Choice and Humana Medicare Employer PFFS do not require members or providers to obtain prior authorization, prior notification or referrals from the plan as a condition of coverage. There is no prior authorization or prior notification rule for Humana Gold Choice or Humana Medicare Employer PFFS members. Note: Medicare supplemental policies, commonly referred to as Medigap plans, cannot cover cost-sharing amounts for Medicare Advantage plans, including PFFS plans. All cost-sharing is the member’s responsibility.

Balance billing of members

There are two different PFFS balance billing scenarios:

  • If the provider is deemed and a non-participating provider under Original Medicare rules, up to 15% balance billing is permitted. However, the plan – not the beneficiary – must pay the 15%.
  • If the provider is deemed or contracted, and the balance billing is explicitly included in Humana’s contract with the provider or in the terms and conditions of payment, it may balance bill up to 15% of the total plan payment amount for services, for which the beneficiary is responsible.

A provider may collect only applicable plan cost-sharing amounts from Humana Gold Choice or Humana Medicare Employer PFFS members and may not otherwise charge or bill members. Balance billing is prohibited by providers who furnish plan-covered services to Humana Gold Choice or Humana Medicare Employer PFFS members.

Hold harmless requirements

In no event, including, but not limited to, nonpayment by Humana, insolvency of Humana, and/or breach of these terms and conditions, shall a deemed provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a member or persons acting on their behalf for plan-covered services provided under these terms and conditions. This provision shall not prohibit the collection of any applicable coinsurance, copayments, or deductibles billed in accordance with the terms of the member's benefit plan.

If any payment amount is mistakenly or erroneously collected from a member, you must make a refund of that amount to the member.

5. Filing a claim for payment

  • You must submit a claim to Humana for an Original Medicare covered service within the same time frame you would have to submit under Original Medicare, which is within 1 calendar year after the date of service. Failure to be timely with claim submissions may result in non-payment. The rules for submitting timely claims under Original Medicare can be found at https://www.cms.gov/MLNMattersArticles/downloads/MM6960.pdf.
  • Prompt Payment: Humana will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, Humana will pay interest on the claim according to Medicare guidelines. A clean claim includes the minimum information necessary to adjudicate a claim, not to exceed the information required by Original Medicare. Humana will process all non-clean claims and notify providers of the determination within 60 days of receiving such claims.
  • Submit claims using the standard CMS-1500, CMS-1450 (UB-04), or the appropriate electronic filing format.
  • Use the same coding rules and billing guidelines as Original Medicare, including Medicare CPT Codes, HCPCS codes and defined modifiers. Bill diagnosis codes to the highest level of specificity.
  • Include the following on your claims:
    • National Provider Identifier.
    • The member's ID number.
    • Date(s) of service.
  • For providers that are paid based upon interim rates, include with your claim a copy of your current interim rate letter if the interim rate has changed since your previous claim submission.
  • Coordination of Benefits: All Medicare secondary payer rules apply. These rules can be found in the Medicare Secondary Payer Manual located at http://www.cms.hhs.gov/Manuals/IOM/list.asp. Providers should identify primary coverage and provide information to Humana at the time of billing.
  • Where to submit a claim:
    • For electronic claim submission, you can use your existing clearinghouse or Availity®. Current Humana electronic submitters can use the same process they now use.
    • For paper claim submission, mail paper claims to the address listed on the back of the member ID card or:

      Humana
      P.O. Box 14601
      Lexington, KY 40512-4601

    • If you have problems submitting claims to us or have any billing questions, contact our technical billing resource at the member/provider service number listed on the back of the member’s identification card.

  • 6. Maintaining medical records and allowing audits

    Deemed providers shall maintain timely and accurate medical, financial and administrative records related to services they render to Humana Gold Choice or Humana Medicare Employer PFFS members. Unless a longer time period is required by applicable statutes or regulations, the provider shall maintain such records for at least 10 years from the date of service.

    Deemed providers must agree to maintain medical records according to industry standards and to provide such records to Humana or a Humana designee upon request and within a reasonable time frame. Deemed providers must provide Humana, the Department of Health and Human Services, the Comptroller General, or their designees access to any books, contracts, medical records, patient care documentation, and other records maintained by the provider pertaining to services rendered to Medicare beneficiaries enrolled in a Medicare Advantage plan, consistent with Federal and state privacy laws. Such records will primarily be used for Centers for Medicare & Medicaid Services (CMS) audits of risk adjustment data upon which CMS capitation payments to Humana are based. Providers are required to furnish member medical records without charge when the medical records are required for government use.

    Humana may also request records for activities in the following situations: Humana audits of risk adjustment data, CMS audits, compliance with federal regulations, Humana determinations of whether services are covered under the plan, are reasonable and medically necessary, and whether the plan was billed correctly for the service; whether the service was coded properly; to investigate fraud and abuse; and in order to make advance coverage determinations. Humana will not use these records for any purpose other than the intended use. Providers are required to furnish member medical records without charge when the medical records are required for government use.

    Humana will not use medical record reviews to create artificial barriers that would delay payments to providers. Both mandatory and voluntary provision of medical records must be consistent with HIPAA privacy law requirements.

    7. Getting an advance organization determination

    Providers or plan enrollees may obtain a written advance coverage determination (known as an organization determination) from us before a service is furnished to confirm whether the service will be covered by Humana Gold Choice or Humana Medicare Employer PFFS plans. To obtain an advance organization determination, all requests must be in writing and mailed to:

    Humana Advance Organization Determination Correspondence
    P.O. Box 14601
    Lexington, KY 40512-4601

    A written advance organization determination request can also be faxed to 502-508-3551. Humana will make a decision and notify you and the member within 14 days of receiving the request, with a possible (up to) 14-day extension either due to the member’s request or Humana’s justification that the delay is in the member’s best interest. In cases where you believe that waiting for a decision under this time frame could place the member’s life, health, or ability to regain maximum function in serious jeopardy, you can request an expedited determination. To obtain an expedited determination, call us at the member/provider service number listed on the back of the member’s identification card or fax a request for an advance organization determination to 502-508-3551. We will notify you of our decision as expeditiously as the enrollee’s health condition requires, but no later than 72 hours after receiving the request, unless we invoke a (up to) 14-day extension either due to the member’s request or Humana’s justification (for example, the receipt of additional medical evidence may change Humana’s decision to deny) that the delay is in the member’s best interest.

    In the absence of an advance organization determination, Humana can retroactively deny payment for a service furnished to a member if we determine that the service was not covered by our plan (e.g., was not medically necessary). However, providers have the right to dispute our decision by submitting a waiver of liability (promising to hold the member harmless regardless of the outcome), and exercising member appeal rights (see the Federal regulations at 42 CFR Part 422, subpart M, or Chapter 13 of the Medicare Managed Care Manual.

    8. Provider payment dispute resolution process

    If you believe that the payment amount you received for a service is less than the amount indicated in our terms and conditions of payment, you have the right to dispute the payment amount by following our dispute resolution process. To file a payment dispute with Humana, send a written dispute to:

    Humana
    P.O. Box 14601
    Lexington, KY 40512-4601

    Additionally, please provide appropriate documentation to support your payment dispute. This should include your name, address, the member’s ID card number and reason(s) for the payment dispute. Please send any supporting medical records, notes or other information that explains why the service(s) should be paid. Claims must be disputed within 180 days from the date payment is initially received by the provider. Note that in cases where we re-adjudicate a claim, for instance, when we discover that we processed it incorrectly the first time, you have an additional 180 days from the date you are notified of the re-adjudication in which to dispute the claim.

    We will review your dispute and respond to you within 30 days. If we agree with the reason for your payment dispute, we will pay you the additional amount you are requesting, including any interest that is due. We will inform you in writing if our decision is unfavorable and no additional amount is owed.

    9. Member and provider appeals and grievances

    Humana Gold Choice and Humana Medicare Employer PFFS members have the right to file appeals and grievances with Humana when they have concerns or problems related to coverage or care. Members may appeal a decision made by Humana to deny coverage or payment for a service or benefit that they believe should be covered or paid for. Members should file a grievance for all other types of complaints not related to the provision or payment for health care.

    A physician who is providing treatment may, upon notifying the member, appeal pre-service organization determinations to the plan on behalf of the member. The physician may also appeal a post-service organization determination as a representative, or sign a waiver of liability (promising to hold the member harmless regardless of the outcome) and appeal the denial using the member appeal process. There must be potential member liability (e.g., an actual claim for services already rendered and denied in whole, as opposed to an advance organization determination or a partially paid claim), in order for a provider to appeal a post-service organization determination utilizing the member appeal process.

    A non-physician provider may appeal an organization determination on behalf of the member as a representative, or sign a waiver of liability (promising to hold the member harmless regardless of the outcome) and appeal a post-service organization determination (e.g., claims using the member appeal process) using the member appeal process. As noted above, there must be potential member liability in order for a provider to appeal a post-service organization determination utilizing the member appeal process.

    If a provider appeals using the member appeal process, the provider agrees to abide by the statutes, regulations, standards, and guidelines applicable to the Medicare PFFS Member appeals and grievance processes.

    The Humana Gold Choice or Humana Medicare Employer PFFS Member Evidence of Coverage (EOC) provides more detailed information about the member appeal and grievance processes. The member EOC is posted to Humana.com. You can call our member/provider service number listed on the back of the Humana Gold Choice or Humana Medicare Employer PFFS member’s identification card for more information on our member appeals and grievance policies and procedures.

    10. Providing members with notice of their appeals rights – Requirements for Hospitals, SNFs, CORFs, and HHAs

    Hospitals must notify Medicare beneficiaries, including Medicare Advantage beneficiaries enrolled in PFFS plans, who are hospital inpatients about their discharge appeal rights by complying with the requirements for providing the An Important Message from Medicare About Your Rights (IM), including complying with the time frames for delivery. For copies of the notice and additional information regarding IM notice and delivery requirements, go to: http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp.

    Skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities must notify Medicare beneficiaries, including Medicare Advantage beneficiaries enrolled in PFFS plans, about their right to appeal a termination of services decision by complying with the requirements for providing the Notice of Medicare Non-Coverage (NOMNC), including complying with the normal time frames for delivery. For copies of the notice and the notice instructions, go to: http://www.cms.gov/BNI/09_MAEDNotices.asp.

    As directed in the instructions, the NOMNC should contain Humana’s contact information somewhere on the form (such as in the additional information section on page 2 of the NOMNC).

    In addition, the provider should send a copy of any NOMNC issued to:

    Humana Correspondence Office
    P.O. Box 14611
    Lexington, KY 40512-4611

    Humana will provide members with a detailed explanation if a member notifies the Quality Improvement Organization (QIO) that the member wishes to appeal a decision regarding a hospital discharge (Detailed Notice of Discharge) or termination of home health agency, comprehensive outpatient rehabilitation facility or skilled nursing facility services (Detailed Explanation of Non-coverage) within the time frames specified by law. For copies of the notices and the notice instructions, go to: http://www.cms.gov/BNI/12_HospitalDischargeAppealNotices.asp and http://www.cms.gov/BNI/09_MAEDNotices.asp.

    11. If you need additional information or have questions

    If you have general questions about Humana Medicare Advantage PFFS plans terms and conditions of payment, contact us at:

    Humana Provider Relations
    333 Main Street
    5th Floor
    Green Bay, WI 54307
    Phone: 1-866-291-9714
    Fax: 1-800-626-1686
    Hours of Operation: 8 a.m. to 7 p.m. Central time, Monday through Friday

    • If you have questions about submitting claims, call us at the member/provider service number listed on the back of the Humana Gold Choice or Humana Medicare Employer PFFS member’s identification card.
    • If you have questions about plan payments, call us at member/provider service number listed on the back of the Humana Gold Choice or Humana Medicare Employer PFFS member’s identification card.