Humana or its designee has the right to conduct prepayment reviews of health care provider records related to services rendered to Humana members. The clinician must allow Humana access to medical records and billing documents to conduct reviews. Humana will not use these prepayment reviews to create artificial barriers that would delay payments.
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 without any additional authorization for the purpose of payment of health care claims. Health care providers who believe that any 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 clinician’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 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.
- 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.
- National Uniform Billing Committee UB-04 Data Specifications Manual.
- American Hospital Association Coding Clinic Guidelines.
- Charge Master Guide guidelines as they relate to and define services billed and any other generally accepted industry standard guidelines.
PPI prepayment 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 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 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 supplies were provided.
- The records and/or documentation substantiate the setting or level of service that was provided to the patient.
Reviews and records requests
Humana may conduct prepayment reviews of claims as required or allowed by applicable law and may request medical records, itemized bills and substantiating documentation to support these prepayment reviews. Health care providers should send copies of requested documentation within 30 days of the request or within the appropriate federal and/or state guidelines. For information on payment for copying fees, please refer to the PPI policy for medical records management
Health care providers can submit requested documentation to Humana via mail, fax, upload or their electronic medical records system. For faster adjudication of your claim, please upload the requested information. For details on submission methods, please refer to the PPI policy for medical records management
If a health care provider does not submit or refuses to provide the requested documentation, he/she may receive a technical denial. Please refer to the PPI policy for technical denial.
If Humana or its designee determines that a coding and/or payment adjustment is applicable, the health care provider will receive the appropriate claim adjudication, explanation of remittance (EOR) and a findings letter. The provider may submit a dispute within 60 calendar days from the date of the EOR. Please refer to the PPI clinical audit dispute process for more information.
Humana will follow all federal and state laws and regulations, Humana policies and procedures and any 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.