Humana (or its designee) conducts prepayment reviews of health care professionals’ records related to services rendered to Humana members. During the review, the health care professional is asked to allow Humana access to medical records and billing documents that support the charges billed.
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 between covered entities without additional authorization for the payment 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 listed 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 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 and Medicaid programs. Examples include, but are not limited to:
These reviews also confirm that:
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, invoices or other substantiating documentation to support the charges billed. Health care professionals are asked to 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 your Humana participation agreement or the Humana Provider Payment Integrity Medical Records Management Policy.
Health care professionals can submit requested documentation to Humana via mail, fax, upload or via an electronic medical records system. For faster adjudication of claims, the requested information should be uploaded. Details on submission methods can be found in the Humana Provider Payment Integrity Medical Records Management Policy.
Health care professionals who do not submit the requested documentation may receive a technical denial which will result in the claim being denied until all information necessary to adjudicate the claim is received. Please refer to the Humana Provider Payment Integrity Technical Denial Policy.
If Humana or its designee determines that a coding and/or payment adjustment is applicable, the health care professional will receive the appropriate claim adjudication, an explanation of remittance (EOR) and a findings letter. Physicians and other health care professionals may have the right to dispute results of reviews. Those who are not in agreement with the explanation or findings may refer to the PPI dispute process for details.
Humana will follow all applicable 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.