For prepayment reviews, medical records and/or related documentation will be reviewed as outlined in the Humana Provider Payment Integrity Prepayment Review Policy.
- Initial request: A letter will be mailed to the health care provider asking that records be provided within 30 days from the date of the letter.
- Second reminder: Communication via telephone is made within seven business days after the initial request.
- Explanation of remittance (EOR) notification: If the requested records are not received within 30 days of the initial request for Medicare Advantage claims or 50 days from the initial request for commercial claims, the health care provider will receive an explanation of remittance, showing the full denial of the claim due to lack of documentation to substantiate the services billed. When additional documentation needed to accurately adjudicate the claim is not provided, Humana will deny the claim due to lack of documentation to substantiate the services billed.
If all requested documentation is received after the technical denial explanation of remittance is sent to the health care provider, the review will be reopened, and the claim will be adjudicated according to the review findings. When additional documentation is needed for the claim to qualify as a clean claim or for Humana to accurately adjudicate the claim, the claim will be pended until the documentation is received or until the deadline for receipt of the documentation passes.