Humana or its designee has the right to conduct audits of health care provider records related to services rendered to Humana members. The clinician must allow Humana access to the medical record and billing documents to conduct audits.
Patient consent may be required to release the requested information. Please ensure that you have obtained consent in accordance with all applicable laws and regulations before releasing the requested records. Health care providers who believe an additional release authorization for an audit is necessary should obtain from Humana members their authorization for release of the medical records to Humana, along with the clinician’s consent-to-treatment forms, or the requirement will be waived if permitted by applicable law.
This audit provision supersedes the health care provider’s internal audit policy and shall survive the termination or expiration of the provider agreement with Humana.
Humana utilizes, but is not limited to, the resources below to ensure that reviews are conducted in a fair manner. These are widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers. A health care provider’s order must be present to support all charges, along with documentation to support the diagnosis and services or supplies that were billed. If there is no specific rule related to a charge in question or a participation agreement does not exist, Humana will employ:
Provider Payment Integrity (PPI) audits look for overutilization of services or other practices that directly or indirectly result in unnecessary costs to the health care industry, including the Medicare program. Examples include, but are not limited to:
These audits also confirm that:
An on-site audit allows an auditor to visit a health care provider to review medical records and billing documents in person. Humana has the following on-site audit guidelines:
If requested by Humana, the clinician will need to resubmit a corrected claim within 45 days following the exit conference in order to receive additional reimbursement for audited claims.
With respect to the audited claims, the health care provider will need to refund any amount Humana has overpaid within the time frame required by applicable state law or, absent a state law requirement, within no less than 45 days following receipt of notification from Humana of such overpayment.
A desk audit allows the health care provider to submit medical record and billing documentation to Humana or its designee. The desk audit process includes the following steps:
Humana will follow all applicable federal and state laws and regulations, Humana policies and procedures and applicable contract language. When more than one state is impacted by a particular issue, to allow for consistency, Humana will follow the most stringent requirement(s). This standard is subject to change or termination by Humana at any time. Humana has full and final discretionary authority for its interpretation and application.