Provider payment integrity audit policies and other resources
Humana’s provider payment integrity (PPI) unit focuses on ensuring that physicians and other health care providers receive accurate payments for their claims. The unit also works to prevent fraud, waste and abuse. The resources below can assist those who interact with PPI’s clinical audits team.
Processes and policies
- Clinical audit dispute process: Learn about the dispute resolution process for physicians and other health care providers who disagree with Humana’s findings.
- Clinical audit record requirements: See a list of records that may be requested.
- Policy for after discharge: Get details on the policy for rebilling Humana following a finding that the inpatient setting was not the most appropriate level of care.
- Policy for medical records management: Get details on submitting medical records to Humana’s provider payment integrity department.
- Policy for post-payment audits: Find out about audit processes.
- Policy for prepayment audits and reviews: Get an explanation of the prepayment review process.
- Policy for technical denial: Learn about the policy for denials that occur when a physician or other health care provider does not respond to a request for medical records from Humana.