Technical denial

Humana Provider Payment Integrity Technical Denial Policy

A technical denial is a denial of the entire paid amount of a claim in instances when the care provided to a member cannot be substantiated due to a health care provider’s nonresponse to Humana’s requests for medical records, itemized bills, documents, etc. If the requested documentation is received after the technical denial is issued, the technical denial will be reversed and the claim will be repaid. For post-payment audits, medical records and/or related documentation will be reviewed as outlined in the Humana Provider Payment Integrity Post-payment Audit Policy.

Prepayment review technical denials

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.

Post-payment technical denials

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:

  • 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: If the requested records are not received within 30 days of the initial letter, a second letter will be mailed to the health care provider, allowing an additional 30 days to respond.
  • Final notice: If the requested records are not received within 60 days of the initial letter, a final letter will be mailed to the health care provider, allowing an additional 30 days to respond.
  • Technical denial letter: If the requested records are not received within 90 days of the initial request, a technical denial letter will be mailed to the health care provider.

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.

On-site audits

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.