Processing  edits

Claims Processing Edits

Humana periodically updates its policies and claims payment systems to be aligned with correct-coding initiatives as well as national benchmarks and industry standards:

  • Centers for Medicare & Medicaid Services (CMS) guidelines
  • American Medical Association (AMA) Current Procedural Terminology (CPT®)
  • Healthcare Common Procedure Coding System (HCPCS)
  • International Classification of Diseases, 9th Edition/Revision (ICD-9)

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. 26, 2015 Oct. 24, 2014
April 13, 2015 Jan. 9, 2015
June 22, 2015 March 21, 2015
Sept. 14, 2015 June 12, 2015
Nov. 9, 2015 Aug. 7, 2015

Submit code edit questions online

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

Code Edit 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)
      • This tool is available to submit questions about edits that would apply to claims scenarios.

Code Edit Simulations

In order to access the "Code Editing Questions" and “Code Edit Simulation” 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 the code editing applications and submit simulations and questions on the secure provider website of Humana.com.

Code Edit Simulator (link opens in new window) 

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 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 publish date. Updates may be viewed and/or downloaded and printed by selecting the appropriate link below. A keyword search is also available for specific topics, procedures, and diagnoses from within the document to help locate information relevant to claims.

Note: Our forms are in Portable Document Format (PDF) and require Adobe Reader for viewing and printing. To get the plug-in, visit Adobe's website to download Adobe Reader (link opens in new window).

Current update list:

Physician/Health Care Providers All Markets (Excluding Puerto Rico) – effective 11/9/2015
(232 KB) Download PDF
Physician/Health Care Providers All Markets (Excluding Puerto Rico) – effective 9/14/2015
(232 KB) Download PDF
Inpatient/Outpatient Facilities All Markets (Excluding Puerto Rico) – effective 11/9/2015
(220 KB) Download PDF
Inpatient/Outpatient Facilities All Markets (Excluding Puerto Rico) – effective 9/14/2015
(220 KB) Download PDF

Compiled updates from 2008 to today:

Physician/Health care providers all markets (excluding Puerto Rico)
(1.1 MB) Download PDF
Inpatient/Outpatient facilities all markets (excluding Puerto Rico)
(1.2 MB) Download PDF

Puerto Rico market (Spanish)

Current list of updates:

Physician/Health care providers Puerto Rico only - effective 6/22/2015
(483 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 6/22/2015
(390 KB) Download PDF

Prior lists of updates

(Physician/Health care providers):

Physician/Health care providers Puerto Rico only - effective 4/13/2015
(506 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 1/26/2015
(303 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 11/8/2014
(506 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 9/13/2014
(506 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 6/21/2014
(506 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 4/5/2014
(506 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 1/18/2014
(506 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 11/9/2013
(506 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 9/14/2013
(414 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 6/22/2013
(257 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 4/13/2013
(253 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 1/26/2013
(253 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 4/24/2012
(293 KB) Download PDF
Physician/Health care providers Puerto Rico only - effective 4/14/2012
(135.5 KB) Download PDF
Puerto Rico only - effective 11/5/2011
(311 KB) Download PDF
Puerto Rico only - effective 6/24/2011
(76 KB) Download PDF
Puerto Rico only - effective 4/1/2011
(314 KB) Download PDF
Puerto Rico only - effective 1/22/2011
(268 KB) Download PDF

Prior lists of updates

(Inpatient/Outpatient facilities):

Inpatient/Outpatient facilities Puerto Rico only - effective 4/13/2015
(506 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 1/26/2015
(314 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 11/8/2014
(506 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 9/13/2014
(506 KB) Download PDF
Inpatient/Outpatient Facilities Puerto Rico Only - effective 6/21/2014
(506 KB) Download PDF
Inpatient/Outpatient Facilities Puerto Rico Only - effective 4/5/2014
(506 KB) Download PDF
Inpatient/Outpatient Facilities Puerto Rico Only - effective 1/18/2014
(506 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 9/14/2013
(423 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 6/22/2013
(257 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 4/13/2013
(326 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 1/26/2013
(326 KB) Download PDF
Inpatient/Outpatient facilities Puerto Rico only - effective 4/24/2012
(293 KB) Download PDF
Puerto Rico only - effective 1/31/2012
(186 KB) Download PDF
Puerto Rico only - effective 11/29/2011
(320 KB) Download PDF
Puerto Rico only - effective 6/7/2011
(330 KB) Download PDF
Puerto Rico only - effective 11/30/2010
(575 KB) Download PDF

Medical Claims Payment Policies

Humana publishes medical claims payment policies online in an effort to provide an avenue of transparency for health care providers and their billing offices.

View claims payment policies