Payment Policies

Humana claims payment policies

Humana is publishing its medical claims payment policies online as a new avenue of transparency for health care providers and their billing offices. This information about reimbursement methodologies and acceptable billing practices may help health care providers bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.

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According to CMS, the initial preventive physical examination is a one-time introductory visit provided during the first 12 months a Medicare beneficiary has Part B benefits. If a beneficiary has had Part B benefits for longer than 12 months, the beneficiary can get an annual wellness visit.
Published Date: 03/24/2015
The Centers for Medicare & Medicaid Services (CMS) allows some physicians and practitioners to opt out of the Medicare Program for a period of two years.
Published Date: 03/09/2015
Humana requests that physicians and health care providers submit all HCPCS drug codes with their corresponding valid NDC.
Published Date: 02/25/2015
A list of some commonly used CPT and HCPCS modifiers, and a high level presentation of how those modifiers are generally used for reimbursement.
Published Date: 02/03/2015
CMS introduced four new HCPCS modifiers, -XE, -XP, -XS and -XU. These modifiers are collectively known as “-X{EPSU} modifiers”.
Published Date: 01/14/2015
Transitional care management (TCM) is part of care management for a member’s transition from a facility setting to the community or home setting. This policy defines the use of CPT Codes 99495 and 99496 to report TCM.
Published Date: 12/31/2014
The AMA introduced new CPT codes for urine drug testing, and created new CPT codes to replace some therapeutic drug assay codes. CMS created HCPCS codes to replace the CPT therapeutic drug assay codes that the AMA is deleting.
Published Date: 12/24/2014
CPT code 77427 represents five sessions of radiation treatment management.
Published Date: 12/24/2014
Assistant at surgery services are those services rendered by physicians or nonphysician practitioners (NPP) who actively assist the physician in charge of performing a surgical procedure.
Published Date: 12/12/2014
The Neonatal Intensive Care Unit (NICU) provides continuous care to a critically ill neonate and involves many advanced technologies and interventions that are unique to the specialty area. These critically ill neonates can suffer from various medical conditions including congenital heart defects, neural tube defects, prematurity, respiratory distress, metabolic disorders, and difficulties with feeding and growth. NICU is comprised of four levels of care. Each level of care has a corresponding revenue code: Level 1, Level 2, Level 3 and Level 4.
Published Date: 12/01/2014
Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.
Published Date: 10/13/2014
Modifier EY is appended to a procedure code to indicate that there is no physician or licensed health care provider order for this item or service.
Published Date: 09/19/2014
A colonoscopy allows the physician to examine the lining of the entire large intestine by using a flexible, fiber optic instrument that is inserted through the anus. The test may reveal inflamed tissue, abnormal growths, and ulcers. However, it is most often used to look for early signs of cancer in the colon or rectum. Special instruments can be passed through the colonoscope to remove any polyps if needed.
Published Date: 09/19/2014
After-hours Current Procedural Terminology (CPT®) codes 99050-99060 can be billed in conjunction with an office visit to indicate services were provided outside regular business hours or resulted in a disruption to regularly scheduled office hours. This policy applies to professional services only. After-hours codes are not intended to replace the evaluation and management services codes.
Published Date: 07/01/2014
According to the Centers for Medicare & Medicaid Services (CMS): Under the resource-based practice expense (PE) methodology, specific PE inputs of clinical labor, supplies, and equipment are used to calculate PE relative value units for each individual service. When multiple diagnostic tests are furnished to the same patient on the same day, most of the clinical labor activities and some supplies are not furnished twice.
Published Date: 07/01/2014
Modifier 22 may be added to a procedure code to indicate that the work required to provide a service was substantially greater than is typically required. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition or physical and mental effort required).
Published Date: 07/01/2014
According to the Centers for Medicare & Medicaid Services, an itemized statement is a listing of each service(s) or item(s) provided to a beneficiary. A statement that reflects a grouping of services or items (such as a revenue code) is not considered an itemized statement.
Published Date: 07/01/2014
According to the American Medical Association, “Modifier 50 is used to report bilateral procedures that are performed at the same operative session” (by the same physician). “Bilateral procedures are procedures typically performed on both sides of the body. The intent of this modifier is for it to be appended to the appropriate unilateral code as a one-line entry on the claim form indicating that the procedure was performed bilaterally.”
Published Date: 06/20/2014
Modifier 62: Two surgeons, neither surgeon acting as an assistant.
Published Date: 06/20/2014
The Centers for Medicare & Medicaid Services (CMS) define certain items as capped rental durable medical equipment (DME). In the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule, CMS identifies the category as “CR.”
Published Date: 06/20/2014
The Centers for Medicare & Medicaid Services (CMS) define certain items as “inexpensive” and “other routinely purchased” durable medical equipment (DME). In the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule, CMS identifies the category as “IN.”
Published Date: 06/20/2014
The Centers for Medicare & Medicaid Services (CMS) defines certain items as oxygen or oxygen equipment. In the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule, CMS identifies the category as “OX.”
Published Date: 06/20/2014
A Transcutaneous Electrical Nerve Stimulator (TENS) is a device that delivers electrical current through electrodes placed on the skin to decrease the patient's perception of pain by inhibiting nerve impulses and/or stimulating the release of endorphins.
Published Date: 06/20/2014
Payment for a procedure that has a global surgical package includes payment for preoperative, intraoperative and postoperative care, as well as payment for various related services, such as complications following surgery, postsurgical pain management and supplies. There are occasions when more than one physician provides services included in the global surgical package of a surgery.
Published Date: 06/20/2014
Medical claims payment policy for telehealth and telemedicine services
Published Date: 06/20/2014