Audit appeal

Provider payment integrity clinical audit dispute process

Physicians and other health care providers have the right to dispute the results of audits performed by Humana or Humana's third-party vendors. A health care provider has three opportunities to dispute Humana clinical audit findings once the initial overpayment determination is made. Dispute outcomes are generally provided within 60 days of Humana’s receipt of the dispute. Reasonable extensions will be granted for all levels of dispute. The term “dispute” as referenced in this policy refers to a dispute related to the findings of the provider payment integrity clinical review of the health care provider’s records.

Level One

Health care providers will receive an initial findings letter detailing the overpayment amount. Those wishing to dispute the findings must submit a formal, written Level One dispute letter along with all relevant documents within 60 calendar days from the date of the findings letter to avoid recoupment. Providers will also receive a final notice from Humana within 45 days of the date of the initial findings letter. Disputed claims will be reviewed by licensed personnel appropriate for the claim type (professional coder, physician, registered nurse, pharmacist, etc.). These personnel are different from the individual who made the initial overpayment determination. If recoupment has not been initiated, the overpayment is placed on hold so that monies are not recouped or offset from future payments until the dispute is resolved.

All Level One disputes should be sent to the Humana Clinical Audit Dispute Team:

Humana Provider Payment Integrity Clinical Audit Disputes

P.O. Box 14279

Lexington, KY 40512-4279

Fax: 1-888-815-8912

Level Two and Three disputes should be sent to the fax number/address above unless there is a specific address indicated in the previous dispute outcome letter.

To ensure proper routing and a thorough and timely review of your dispute, please include a copy of the dispute request form along with the original findings letter, previous dispute outcome letters and any other documentation that supports your dispute.

Level Two

Health care providers can respond to the Level One dispute outcome letter by submitting a written Level Two dispute request. Any supporting documentation not previously submitted may accompany this letter and must be submitted within 60 days from the date on the Level One dispute outcome letter. Once received, the Level Two dispute is sent to a third-party reviewer. The third-party reviewer differs from the original entity that conducted the initial claim review, and also conducts similar audits for the Centers for Medicare & Medicaid Services (CMS) in the Recovery Audit Contractor (RAC) program. If recoupment has not been initiated, the overpayment is placed on hold so that the monies are not recouped or offset from future payments until the dispute is resolved.

All Level Two disputes should be sent to the Humana Clinical Audit Disputes Team *unless there is a specific address indicated in the previous disputes outcome letter:

Humana Provider Payment Integrity Clinical Audit Disputes

P.O. Box 14279

Lexington, KY 40512-4279

Fax: 1-888-815-8912

*Nonparticipating short stay audit disputes that have already gone through Level One of the PPI process will be directed to Humana’s grievance and appeals (G&A) team and will begin at Level One of the G&A team’s review.

To ensure proper routing and a thorough and timely review of your dispute, please include a copy of the dispute request form, the original findings letter, previous dispute outcome letters and any other documentation that supports your dispute.

Level Three

Health care providers can respond to the Level Two dispute outcome letter by submitting a written Level Three dispute request. Supporting documentation not previously submitted may accompany this letter and must be submitted within 60 days from the date of the Level Two dispute outcome letter. The internal clinical physician review team, the internal coding team or a third-party reviewer will conduct the review depending on the type of audit and expertise required. The third-party entity differs from those that conducted prior reviews, and is URAC-accredited with an expansive network of actively licensed medical doctors and coders certified by the American Health Information Management Association (AHIMA).

All Level Three disputes should be sent to the Humana Clinical Audit Dispute Team unless there is a specific address indicated in the previous dispute outcome letter:

Humana Provider Payment Integrity Clinical Audit Disputes

P.O. Box 14279

Lexington, KY 40512-4279

Fax: 1-888-815-8912

To ensure proper routing and a thorough and timely review of your dispute, please include a copy of the dispute request form, the original findings letter, any previous dispute outcome letter and any other documentation that supports your dispute.