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:
- Centers for Medicare & Medicaid Services (CMS) billing guidelines as stated in Medicare provider reimbursement manuals.
- Humana policies, including medical coverage policies and code-editing policies.
- National Uniform Billing Guidelines from the National Uniform Billing Committee.
- American Medical Association Current Procedural Terminology (CPT®) guidelines.
- ICD-9-CM Official Guidelines for Coding and Reporting or its successor.
- American Association of Medical Audit Specialists National Health Care Billing Audit Guidelines.
- Industry standard utilization management criteria and/or care guidelines.
- UB-04 Data Specifications Manual.
- American Hospital Association.
- American Medical Association Coding Clinic Guidelines and Charge Master Guide guidelines as they relate to and define services billed and any other generally accepted industry standard guidelines.
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:
- Improper payment for services.
- Payment for services that fail to meet professionally recognized standards/level of care.
- Charges in excess or selection of the wrong code(s) for services or supplies.
- Billing for items or services that should not have been or were not provided based on documentation supplied.
- Unit errors, duplicate charges and redundant charges.
- All required documentation is not present in the medical record.
- Experimental and investigational items billed.
- Items not separately payable, such as routine nursing, capital equipment charges, etc.
These audits also confirm that:
- The most appropriate and cost-effective services and supplies were provided.
- The records and/or documentation substantiate the setting or level of service that was provided to the patient.