After Discharge

Provider payment integrity clinical audit record requirements

Overview

Humana, or its designee, has the right to conduct audits of physicians’ and other health care providers’ records related to services rendered to Humana members in certain circumstances. As stated in their contracts, physicians and other health care providers will, upon request, grant Humana access to medical records and billing documents to conduct audits. Detailed itemizations of charges should be available to support the supplies and services billed.

For an overview of the audit and review process, please refer to the post-payment audit process overview and the provider payment integrity policy for prepayment reviews.

The records and/or documentation should substantiate the services that were provided to the patient. In the event a physician or other health care provider does not submit or refuses to provide a medical record, he/she may receive a technical denial. Please refer to the provider payment integrity policy for technical denial.

Record types we may request include, but are not limited to:

  • Activities of daily living (ADL) sheet, including flow sheets and/or logs.
  • Admission assessments.
  • Anesthesia records (including time of anesthesia administration).
  • Case management notes.
  • Change of therapy (COT) assessment.
  • Chat logs.
  • Chemotherapy orders.
  • Clinical trial information, including consents and treatment plans.
  • Consultation notes.
  • Itemized bill.
  • Diagnosis notes, including past medical history.
  • Discharge/transfer summaries.
  • Drawings and photos, when applicable.
  • Emergency department reports.
  • Evaluations: any evaluation related to the service provided.
  • Face sheet.
  • Face-to-face encounter documentation.
  • For durable medical equipment/home infusion/home health: delivery receipt for supplies or drugs/proof of delivery.
  • For inpatient rehabilitation: patient assessment instrument (PAI).
  • Letter/certificate of medical necessity (CMN) for services.
  • For skilled nursing facilities: minimum data set (MDS).
  • Hospice/end-of-life-care documentation.
  • Implant detail: sticker sheet and copy of invoices for implants or high-cost drugs; implant logs with additional information on implants, screws and plates. Laboratory reports and X-rays from ordering physician, along with written interpretations of X-rays, tests and/or laboratory results. Copy of invoices for implants or high-cost drugs; implant logs with additional information on implants, screws and plates.
  • Medication records/medication administration records (MAR), including strength, National Drug Code (NDC) and waste, mixing logs, infusion medication sheet and transfusion/infusion logs.
  • Nurse or any other health care provider’s progress, treatment, SOAP (subjective/objective assessment and plan), dietary and daily notes.
  • Obstetric/newborn services.
  • Operating reports and records.
  • Operative reports.
  • Patient history.
  • Physical exam.
  • Physician office records: complete records, including office visit documentation, demographic/face sheet, member history, laboratory and procedure results and all correspondence with other health care providers, including consultation requests and reports.
  • Physician orders.
  • Plans of care (POCs), treatment plans (tried and failed conservative treatments) and any related evaluations and updates or recertifications for the time period during which the member was treated. The POC and recertifications should be signed by a physician.
  • Preanesthetic evaluation.
  • Preoperative and postoperative notes.
  • Prescriptions.
  • Progress notes.
  • Psychiatric evaluation notes.
  • Physician query (if applicable): If the facility's coder requests additional information from the physician for clarification on documentation, he/she would submit a query to the physician.
  • Skilled nursing, physical therapy, occupational therapy, speech therapy, respiratory therapy and medical social worker (MSW) documentation, including notes and therapy logs that detail the number of minutes each service was provided.
  • Test orders/results/reports including, but not limited to, pathology, radiology and laboratory (include results, when applicable).
  • The outcome assessment information set (OASIS) for home health claims; this must be completed in its entirety. All six digits of the diagnosis code must exactly match between POC, OASIS and the claim. Any correction must be applied by the end of the episode; fields cannot contain N/A, OASIS; fields M2200 and M0110 cannot be blank or contain N/A.
  • Toxicology reports.
  • Treatment notes.
  • Uniform billing form (UB-04).
  • Wound care assessment.