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.
A technical denial will be issued after the third failed attempt to obtain medical records from the health care provider of a service on a claim. The timeline for these requests is as follows:
The health care provider will have 45 days from the date on the technical denial letter and the financial recovery overpayment letter to send in records before the paid amount of the claim is recouped.
In the case of an on-site audit, Humana or Humana’s designee will contact the provider audit representative to schedule the audit. Health care providers should respond to a scheduling request within 30 days of receipt of the request and schedule the audit on a mutually agreed date and time. If a scheduled date is not confirmed by the clinician within 30 days of the initial request, Humana or the designee will attempt to contact the facility via phone, email or letter. If there is still no response, two additional attempts will be made (30 days apart). If Humana or its designee is still unsuccessful at scheduling a date for the on-site audit after these attempts, a technical denial will be issued. Once the audit has been scheduled, the technical denial will be reversed, and the claim will be repaid.
Humana will follow all 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.