Claims Processing Edits

Humana periodically updates its policies and claims payment systems to be aligned with correct-coding initiatives, Centers for Medicare & Medicaid Services (CMS) guidelines, national benchmarks and industry standards, such as the American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, 9th Edition/Revision (ICD-9) code sets regarding physician/health care provider claims and facility claims. These updates support Humana's continuing efforts to process claims accurately.

The schedule of updates and notifications is as follows:

Implementation Dates

Dates available to view on Humana.com

Jan. 18, 2014 Oct. 18, 2013
April 5, 2014 Jan. 3, 2014
June 21, 2014 March 21, 2014
Sept. 13, 2014 June 13, 2014
Nov. 8, 2014 Aug. 8, 2014

Download and Print

Code Edit and Policy Change Notifications

Posted below is a list of the most current notifications of changes, as well as a compiled list of updates that were posted previously for physicians/health care providers and for facility claims from November 2008 through today. (Please note: These are not all-inclusive lists of every policy and code edit that may be applied to claims by Humana.) Puerto Rico market versions of the notifications are in their original format in a separate table below.

The lists include a general category, a specific topic, a detailed statement of the policy or update, the products that are affected by the statement and the status of the policy or update (e.g., active, edit not implemented, delayed, etc.). The files list general reminders first, and then are sorted by the category, topic, the detailed statement and effective date. Updates may be viewed and/or downloaded and printed by selecting the appropriate link below. Keyword search is also available for specific topics, procedures or diagnoses from within the document to help locate information relevant to claims.

Current Update List:

Physician/Health Care Providers All Markets (Excluding Puerto Rico) – effective 6/21/2014
(262 KB) Download PDF
English

Inpatient/Outpatient Facilities All Markets (Excluding Puerto Rico) – effective 6/21/2014
(253 KB) Download PDF
English

Compiled Updates from 2008 to Current:

Physician/Health Care Providers All Markets (Excluding Puerto Rico)
(1.1 MB) Download PDF
English

Inpatient/Outpatient Facilities All Markets (Excluding Puerto Rico)
(1.2 MB) Download PDF
English

Submit Code Edit Questions Online

Additional information about code-editing changes is available via the "Code Editing Questions" application on the secure provider area of Humana.com/providers (registration required). Health care providers may follow these steps to submit questions:

  • On Humana.com/providers, select the "Log In" button
  • Log in using the fields under "Log In"
  • On the "Claims Tools" tab, select "Code Editing Questions" under "Associated Links" to submit question(s)

In order to access the "Code Editing Questions" application, you must be registered on Humana's website. Health care providers may follow these instructions to register:

  • On Humana.com/providers, select the "Register" button
  • Select "Provider" on the "Please tell us who you are" screen to start the provider registration process
  • Follow the instructions on the page to move through the application process

Once the registration process is complete, the health care provider will be able to access "Code Editing Questions" and submit questions on the secure provider website of Humana.com

Puerto Rico Market (Spanish)

Current list of updates:

Physician/Health Care Providers Puerto Rico Only - effective 1/18/2014
(506 KB) Download PDF
Spanish

Inpatient/Outpatient Facilities Puerto Rico Only - effective 1/18/2014
(506 KB) Download PDF
Spanish

Physician/Health Care Providers Puerto Rico Only - effective 11/9/2013
(506 KB) Download PDF
Spanish

Physician/Health Care Providers Puerto Rico Only - effective 9/14/2013
(414 KB) Download PDF
Spanish

Inpatient/Outpatient Facilities Puerto Rico Only - effective 9/14/2013
(423 KB) Download PDF
Spanish

Physician/Health Care Providers Puerto Rico Only - effective 6/22/2013
(257 KB) Download PDF
Spanish

Inpatient/Outpatient Facilities Puerto Rico Only - effective 6/22/2013
(257 KB) Download PDF
Spanish

Physician/Health Care Providers Puerto Rico Only - effective 4/13/2013
(253 KB) Download PDF
Spanish

Inpatient/Outpatient Facilities Puerto Rico only - effective 4/13/2013
(326 KB) Download PDF
Spanish

Physician/Health Care Providers Puerto Rico only - effective 1/26/2013
(253 KB) Download PDF
Spanish

Inpatient/Outpatient Facilities Puerto Rico only - effective 1/26/2013
(326 KB) Download PDF
Spanish

Physician/Health Care Providers Puerto Rico only - effective 4/14/2012
(135.5 KB) Download PDF
Spanish

Inpatient/Outpatient Facilities Puerto Rico only - effective 4/24/2012
(293 KB) Download PDF
Spanish

Prior Lists of updates (Physician/Health Care Providers):

Physician/Health Care Providers Puerto Rico only - effective 4/14/2012
(135.5 KB) Download PDF
Spanish

Physician/Health Care Providers Puerto Rico only - effective 4/24/2012
(293 KB) Download PDF
Spanish

Puerto Rico only - effective 11/5/2011
(311 KB) Download PDF
Spanish

Puerto Rico only - effective 6/24/2011
(76 KB) Download PDF
Spanish

Puerto Rico only - effective 4/1/2011
(314 KB) Download PDF
Spanish

Puerto Rico only - effective 1/22/2011
(268 KB) Download PDF
Spanish

Prior Lists of updates (Inpatient/Outpatient Facilities):

Puerto Rico only - effective 1/31/2012
(186 KB) Download PDF
Spanish

Puerto Rico only - effective 11/29/2011
(320 KB) Download PDF
Spanish

Puerto Rico only - effective 6/7/2011
(330 KB) Download PDF
Spanish

Puerto Rico only - effective 11/30/2010
(575 KB) Download PDF
Spanish

Significant Edits
View a list of edits that affect at least 500 claims per year and differ from AMA CPT or CMS Correct Coding Initiative (CCI) coding guidelines.

Significant Edits
(20.2 KB) Download PDF
English

Modifier 59 Edits
View a list of code combinations that Humana has determined are not appropriately reported together with a modifier 59 and which differ from AMA CPT coding guidelines.

Modifier 59 Edits
(17.9 KB) Download PDF
English

Claims Payment Policies

Humana has a new avenue of transparency for health care providers and their billing offices. The claims payment policies listed below include information about reimbursement methodologies and acceptable billing practices that may help reduce delays in processing claims, and avoid rebilling and additional requests for information.

The list of policies available online will continue to grow over time, and new and updated policies will be published frequently. The goal is to post claims payment policies as they are implemented so health care providers can easily access the most current information.