Humana Promotes Medicare Advantage Member and Primary Physician Relationship

As Humana continues its progress in connecting Medicare Advantage PPO members to primary physicians, beginning in plan year 2014, Medicare Advantage (MA) HumanaChoice(PPO) plans will require that members select a primary physician to focus on the member's health care needs and coordinate care as needed. Although members are required to select a primary physician, members do not need to get referrals for services or to see other doctors.

The Centers for Medicare & Medicaid Services (CMS) star ratings hold MA health plans accountable for their members receiving recommended preventive care services and timely access to care. We also have an obligation to help our members maximize their MA health plan benefits. We hope that by selecting a primary physician members will have the clinical support needed to facilitate coordination of care.

What does this mean for health care providers?

  • Members will select a primary physician as the person they want to coordinate their care.
  • The member's primary physician will be listed on the back of the member's Humana ID card.
  • Health care providers will continue to work as they do today regarding clinical management of Humana MA PPO and MA Private Fee-for-Service (PFFS) members.
  • If a member chooses a new primary physician, the individual will receive a new member ID card that reflects the change.
  • Health care providers will not need a referral to see Humana MA PPO, MA PFFS and some MA HMO members.
  • Humana MA PPO and MA PFFS members still have the freedom and flexibility to see the health care provider of their choice, regardless of specialty.
  • To facilitate continuity of care, it is critical that specialists' offices forward results of office visits and tests to patients' primary physicians. If information is not received, primary physicians' offices should follow up with the specialist to obtain results for the patient's medical records.
  • We have developed a simple form, the Primary Treating Physician Change Request Form, which health care providers can use to ensure that the MA members they serve are correctly attributed to their practice.

Other Frequently Asked Questions and Answers

Q: What types of physicians can be listed as a primary physician?

A: Primary physicians are typically (but are not required to be) one of the following:

  • Family practitioners
  • General practitioners
  • Internists
  • Obstetricians/Gynecologists
  • Nurse practitioners (where applicable)

Q: Why should health care providers encourage their patients to choose a primary physician?

A: We hope that this effort will encourage our members to actively engage in managing their health, well-being and benefits. We believe that choosing a primary physician will provide the following benefits for our members:

  • Regular checkups and preventive care to avoid costlier care later
  • Central point for medical records
  • Monitoring and management of chronic conditions
  • Routine and urgent care
  • Medication coordination and management
  • Specialist recommendations
  • Follow-up care after a hospital stay
  • Healthy lifestyle choice information

Q: How can a health care provider obtain a list of members who have chosen him or her as their primary physician?

A: In order to receive a monthly roster report, health care providers must first request a roster on Humana.com or Availity.com. This request is only required once.

To request a roster report on Humana.com:

Once logged into the secure provider website Humana.com (registration required), choose "Resources," then "Request Medicare Member Roster" under the “Resources and Communications” heading. If more than one organization is associated with the tax ID on the user's account, the user will need to select an organization for which the report will be created. The user will need to complete the request form and choose “submit” in order to request the report.

To request a roster report on Availity.com:

Once logged into the secure provider website Availity.com (select markets only, registration required), choose “Administrative Reporting” then “Request Medicare Member Roster.” The user will need to complete the request form and choose “submit” in order to request the report.

Health care providers may sign up to receive a roster at any time. Reports are available after the 23rd of each month.

Q: What should a health care provider do after receiving the roster notification?

A: When a report is ready to be accessed via Humana.com/providers, a notification informing the health care provider that the report is ready to view will be triggered through the bulletin board system (BBS). This is the same process used today for existing Service Fund downloads.

Once a health care provider receives the BBS notification, the roster report can be accessed on Humana.com/providers by using the “Service Fund Download” link. To find this link, log into the secure provider website at Humana.com/providers, choose “Resources,” then “Service Fund Download” under the “Resources and Communications” heading.

To access these reports on Availity.com, the health care provider must log into Availity.com, choose “Administrative Reporting” and then “Service Fund Download.”