Humana (or its designee) conducts post-payment reviews of health care professionals’ records related to services rendered to Humana members. During such reviews, the professional should allow Humana access to the medical record and billing documents that support the charges billed.
The Treatment, Payment and Health Care Operations (TPO) exception under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR 164.506) allows the release of medical records containing protected health information between covered entities without an additional authorization for the purpose of payment and review of health care claims. Health care professionals who believe that an additional release authorization for this review is necessary should obtain from Humana members their authorization for release of the medical records to Humana, along with the provider’s consent-to-treatment forms, or the requirement will be waived if permitted by law.
Humana utilizes, but is not limited to, the resources below to conduct its reviews. These are widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers. A health care professional’s order must be present to support all charges, along with clinical documentation to support the diagnosis and services or supplies that were billed.
Humana PPI post-payment reviews look for overutilization of services or other practices that directly or indirectly result in unnecessary costs to the health care industry, including the Medicare and Medicaid programs. Examples include, but are not limited to:
These reviews also confirm that:
An on-site review allows a reviewer to visit a health care professional to review medical records and other billing documentation in person. Humana has the following on-site review guidelines:
A desk review allows the health care professional to submit medical record and billing documentation to Humana or its designee for the post-payment review. The desk review 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.