Humana updates to preauthorization and concurrent review process for Medicare Advantage member inpatient admissions

Humana is changing its preauthorization and concurrent review process for inpatient admissions, currently included on our Medicare Advantage Preauthorization and Notification List. This process will include a medical necessity review of inpatient admission requests at the time the request is submitted and a coverage determination is made. The process change will be effective January 18, 2014, for all Humana Medicare Advantage (MA) HMO and PPO plans for the list of codes posted here. Thirty days after the effective date, the process change will be implemented for all Humana MA HMO and PPO member inpatient admission requests. Please continue to use the same process you use today for MA Private Fee-for-Service (PFFS), Medicaid and commercial members, as well as behavioral health facility inpatient admissions. This process is effective November 1, 2013, for Humana's Tennessee MA PPO plans, for Humana's Alabama MA HMO and PPO plans and for Humana's southwest Virginia MA HMO plans.

Health care providers are requested to contact Humana online or via telephone for inpatient admissions. Health care providers may use the secure provider area of Humana's website at Humana.com/providers (registration required) or Availity.com (registration required). Alternatively, health care providers may use the interactive voice response (IVR) line by calling 1-800-523-0023. Health care providers must provide the facility tax ID number, member name, Humana member ID number, member date of birth, admission or service date and diagnosis.

We currently require preauthorization for all inpatient admissions, but only some of those inpatient admissions require a clinical review. Humana's new process will utilize on-site and telephonic nurses to conduct a collaborative clinical review of inpatient services. When requested, a peer-to-peer consultation with a Humana medical director will be available.

In addition, please note the following:

  • Services (including professional fees) that are not medically necessary may not be covered and denied payment.
  • Admissions found not to be medically necessary will not be covered and denied payment.
  • Claims submitted without a review of the admission will be subject to retrospective review, and all claims will continue to be subject to claim code-edits, proper billing, etc. All elective inpatient admissions must be preauthorized prior to admission.
  • Please notify Humana of all emergent admissions within one day of admission.

Health care providers' assistance with Humana's inpatient admission preauthorization and concurrent review process will facilitate the timely processing of claims and decrease the need for retrospective audits and financial recovery.

Exclusions to this requirement include the following:

  • Puerto Rico
  • South Florida
  • Central Florida
  • North Florida LPPO
  • Behavioral health providers
  • Risk providers
  • Providers with contract limitations
  • Delegated utilization management (UM) providers

Following are some questions and answers regarding this process change:

  • 1. Q: Why is Humana changing its inpatient admission preauthorization and concurrent review process?

    A: These changes decrease the need for retrospective audits and financial recovery.

  • 2. Q: Which health care providers will be receiving communications explaining the enhancement?

    A: Affected health care providers are being informed via a letter on or before October 18, 2013.

  • 3. Q: Will health care providers experience a delay in claims payment as a result of this change?

    A: No. This review program will help Humana capture more accurate information, which should facilitate claims review and payments.

  • 4. Q: How are claims paid if Humana denies some of the days associated with an inpatient admission?

    A: All claims are subject to retrospective review. Any inpatient admission/service not meeting medical necessity may be denied. All claims have the potential to be denied or reviewed.

  • 5. Q: What happens if a health care provider does not provide the necessary information?

    A: If the health care provider does not return the necessary clinical information to review the request for medical necessity, we will review the information available, and make a coverage/payment decision. If medical necessity is not met, the claim will be denied. All claims have the potential to be denied or reviewed.

  • 6. Q: Is there an appeal process?

    A: Yes. The appeal process has not changed. Information regarding how to submit an appeal is provided in the denial notification.

  • 7. Q: Which providers are affected?

    A: Medicare Advantage HMO- and MA PPO-contracted providers, except behavioral health providers.

    This includes the following:

    • Primary care physicians
    • Specialists
    • Hospitals
    • Long-term care hospitals
    • Rehabilitation facilities
    • Skilled nursing facilities