Health care providers who have entered into a capitated agreement with Humana will receive a check per member/per month (PMPM) regardless of whether they see the member. Capitation may be paid to primary care providers (PCPs) and specialist groups with which the PCPs are contracted, such as dermatology, cardiology, etc.
Capitation amounts can be a flat rate calculated by Humana or a percentage of premium determined by CMS. Capitation rates are defined in health care providers’ contracts with Humana.
Humana does not expect an impact to capitation. Our capitation reconciliation will follow the normal process.
No. CMS defines DRG codes. DRGs will be based on ICD-10 codes when ICD-10 is implemented.
Humana currently uses version 32 DRG grouper logic. We will continue to transition to the latest groupers as they are released by CMS.
An encounter is a unique type of claim. Encounter data are used to determine a member’s health status. Encounter data are submitted by physicians or physician groups that have a capitated agreement with Humana or are delegated for claims.
Although encounters do not generate payments to the rendering provider, encounter information is used for Healthcare Effectiveness Data and Information Set (HEDIS®) reporting. Also, encounters are a primary driver for risk-adjustment scoring.
If diagnosis codes are fully documented on a Medicare Advantage member’s encounter, then Humana can accurately identify a member’s diagnosis and enroll the member in clinical programs that will assist in managing his/her more serious conditions.
Encounters/claims must contain all diagnosis codes for which the member was treated and/or monitored during his or her visit and which are appropriately documented in the medical record. This includes chronic conditions and/or comorbidities that may affect the medical decision-making for the patient during that encounter.
No. The ICD-10 code set is not valid until Oct. 1, 2015, and ICD-10 codes will not be accepted before the implementation date. Claims submitted after the implementation date that contain dates of service before the implementation date must use ICD-9 codes.
Yes. Humana’s ICD-10 program team has a communication plan and schedule for keeping Humana’s testing partners, trading partners, health care providers and internal departments informed. Humana.com has an ICD-10 site located on the Humana.com medical provider portal. Humana’s YourPractice, Humana’s online provider newsletter, also contains ICD-10 information.
You may visit the ICD-10 site at Humana.com/ICD10.
You may view Humana’s YourPractice publication at Humana.com/publications.
Humana’s internal systems have been remediated and are ICD-10 ready. However, Humana’s system remediation changes will not be visible to health care providers. Humana’s ICD-10 program began in 2009, and Humana will continue external testing through the compliance date.
Denials and appeals will follow the existing process.
Yes. Humana began conducting external end-to-end testing with a select group of early adopters (facilities) in 2012. We began testing with a select group of physicians and claim delegates in early 2015. Humana’s testing with facilities and physician groups is currently at capacity, and we are not able to accept new testing partners.
Yes. Humana will follow the current claims submission process.
Humana will support both ICD-9 and ICD-10 coding formats for a period of time after the compliance date. However, Humana will accept only correctly formatted claims, both electronic and paper, which contain ICD-10 codes for service dates and discharge dates on or after the compliance date. Humana will accept ICD-9 codes for service dates or discharge dates prior to the compliance date for the contracted run-out period or timely filing requirements.
No. Humana has invested in remediation of systems and processes to support ICD-10 requirements. Our advance testing will help mitigate claims-processing issues.
For outpatient services only: No. Per CMS, Humana will require claims with dates of service that extend past the compliance date to be split into separate claims. This means that all services that occur before the compliance date should use ICD-9 codes and should be billed separately from services with dates of service on or after the compliance date, which should contain only ICD-10 codes.
For inpatient service only: Yes. The date of discharge will determine which ICD code set should be used. For inpatient services, if the date of discharge is on or after the compliance date, the claim should be submitted using only ICD-10 codes. If the date of discharge is before the compliance date, ICD-9 codes should be used.
Humana will follow CMS or current state filing requirements. Here is a link to CMS guidance on claims that span the compliance date. Humana will follow this guidance:
Humana began accepting authorizations and referrals with ICD-10 codes on July 1, 2015, and will continue to accept authorizations/referrals with ICD-9 codes for 12 months after the implementation date.
If an authorization is requested on or before the compliance date and the date of service is on or after Oct. 1, 2015, providers may submit an ICD-10 code, though ICD-9-coded authorizations/ referrals will also be accepted.
If the authorization is requested on or after the compliance date, Humana will accept and retain ICD-10 codes and will also allow ICD-9 submissions, just not on the same authorization or referral. Humana will not accept any ICD-9 authorization codes after Sept. 30, 2016.
No. Humana does not anticipate the use of timely filing extensions.
Yes. Reporting formats that include ICD-9 today will be remediated to reflect ICD-10 codes.
No. ICD-10 will be applied through all products and platforms.
No. The date of service determines the compliant code format to be used on a claim, regardless of the date the claim is filed or submitted.
Health care providers must submit claims before the compliance date with ICD-9 codes when the services were performed prior to the compliance date. .
Payers will process claims if received on or after the compliance date with ICD-9 codes when the services were performed prior to the compliance date. .
This situation is HIPAA-compliant. .
Yes. Humana will accept 837 batches containing both ICD-9 and ICD-10 claims as long as both codes are not contained on the same claim.
Humana will follow current CMS guidelines. Per CMS, each health care encounter should be coded to the level of certainty known for that encounter. Clinicians should report unspecified codes when such codes most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It is inappropriate to select a specific code that is not supported by the medical record documentation.
Yes. The version 5010 companion guide can be located through the following link:
They will be rejected at point of receipt.
No. Resubmission processes will continue to follow current guidelines.
All eligibility transactions using a diagnosis code must be compliant with ICD-10 upon the compliance date.
No. Humana does not support interim billing.
Humana publishes current ICD-10 information and training opportunities at
The health care community should visit the CMS website for the most current ICD-10 information:
General Equivalence Mappings (GEMs) are a CMS translation tool that can be used to convert large sets of data from ICD-9 to ICD-10. According to CMS, GEMs are useful in converting databases but are not a substitute for learning how to use ICD-10 codes. Mapping links the two code sets without considering the patient’s medical record information. Coding involves choosing the appropriate code based on the medical record documentation.
Yes. Humana is using CMS GEMs as a guideline to map ICD-9 codes to ICD-10 codes. However, based on clinical guidance and coding expertise, there may be instances when Humana finds additional codes appropriate, above and beyond the GEMS mappings. Humana always recognizes a GEMS-proposed mapping.
No. Humana will process claim transactions in their native format and will not cross-walk ICD-9 codes to ICD-10. Claims with improper diagnosis codes (based on date of service or date of discharge) will be rejected.
Medicaid risk adjustment is a process used to calculate payments related to the treatment of select conditions known as “disease categories.” Reimbursement for services related to these conditions is weighted based on the relative health of a beneficiary.
Medicaid plans vary by state, but the key to accurate Medicaid reimbursement is to code accurately and to the highest level of specificity to ensure the disease categories are triggered, if warranted.
Yes. Humana has reviewed and updated its medical policies to incorporate new ICD-10 terminology and expanded coding. Humana publishes medical policies on its provider website at Humana.com. Choose “For Providers” then select “Medical and pharmacy coverage policies” under the “Resources” heading. Humana has updated medical policies to reflect ICD-10 changes. The policies section of the website also includes Information on medical necessity requirements, coverage determinations and payment determinations.
HCCs represent categories of health conditions, both chronic and acute, that are used to project health care costs for Medicare Advantage members for current and future coverage periods. Diagnosis codes are mapped to HCCs for conditions such as diabetes, congestive heart failure, etc. Members may have multiple HCCs.
CMS posted a preliminary ICD-10-HCC crosswalk on Feb. 24, 2014. There are approximately 10,100 diagnosis codes that have been identified as appropriate for Medicare risk adjustment, and these are mapped to the various HCC models.
Each HCC is assigned a decimal value that contributes to the member’s risk score.
Risk adjustment is a process in which per-member reimbursements from CMS are adjusted to correspond with the member’s health status, which is based upon submitted diagnosis codes. When encounters are not submitted, Humana and CMS do not have complete member information. Risk adjustment was implemented to reimburse Medicare Advantage plans more accurately for predicted health cost expenditures for members by adjusting payments based on demographics (e.g., age and gender), as well as health status.
Increased coding accuracy helps Humana identify members who may benefit from disease and medical management. Accurate health information is used to match health care needs to the appropriate level of care.
For outpatient services, ICD-10 codes are required for dates of service on or after the compliance date. For inpatient services, ICD-10 codes are required on the date of discharge on or after the compliance date.
No. CPT and HCPCS coding for outpatient procedures are not affected. ICD-10 procedure codes apply to hospital inpatient procedures only.
Yes. Claims for patients in-house over the transition date should be submitted based on the discharge date, using the most recent CMS recommendations.
Humana suggests that health care providers stay up to date on changes from CMS regarding ICD-10 implementation via the CMS website and the other resources listed below.
Not necessarily. While ICD-10 provides a larger code set, most specialists typically use a narrow range of diagnosis codes. The American Academy of Professional Coders (AAPC) has published a crosswalk of the top 50 codes for 16 specialties here: www.aapc.com/ICD-10/crosswalks/pdf-documents.aspx. This crosswalk does not replace ICD-10 coding training, and we strongly advise you seek recommended resources and look to your professional associations for training and guidance.
Yes. We currently have diagnosis-related groups (DRG) and ICD contract language in a small percentage of our contracts, and Humana will work with health care providers to update contracts where required. Contract changes will follow the normal process. If a health care provider’s contract has specific ICD or DRG language, he or she should contact the appropriate market representative to facilitate a contract revision. If you are unsure how to locate your market representative, please contact provider relations at 1-800-626-2741.
Health care providers need to contact their software vendors for requirements.
We do not have a subscription list, but we do post ICD-10 information at Humana.com/ICD10. Additionally, if you have an ICD-10 question not answered here, you may send it to ICD10Inquiries@humana.com.
Humana does not expect a delay in payment or policy changes regarding the way a claim is adjudicated under ICD-10. Prompt payment can occur if claims are properly coded based on the latest CMS guidelines. Claims may be reviewed or denied if an ICD-10 code is not consistent with an applicable Humana or CMS policy.
IMPORTANT: The information contained on this website is designed to provide a general overview of what can be expected with the transition from the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, (ICD-9) to ICD-10 as it impacts Humana’s business. The information provided is not intended to address all of the Centers for Medicare & Medicaid Services (CMS) requirements and implications mandating the use of ICD-10 and should not be used as legal advice for implementation activities. We encourage you to seek any professional advice you may need, including legal counsel, regarding how the new requirements will affect your specific practice. Humana provides the information on this site for general informational purposes only.