This webpage offers information about processes that may impact the payments you receive from Humana.
Estimating patient responsibility
Humana’s benefit estimator is a secure web tool you can use to create a personalized estimate of a patient’s payment responsibility. The estimate is specific to the healthcare provider and treatment/service and based on a real-time snapshot of the patient’s benefits. This facilitates financial discussions between you and your patients so that payment arrangements can be made at the time of service.
To take advantage of this tool, you must be a registered Availity Portal user.
Locating this tool on Availity portal
On Availity Portal, you can access the benefit estimator through the “Patient Cost Estimator” button:
- Log in at , opens new window with your Availity username and password.
- Open the “Patient Registration” drop-down menu from the top navigation bar.
- Select the “Eligibility and Benefits Inquiry” link to look up your patient’s coverage.
- On the Eligibility and Benefits results, select the “Patient Cost Estimator” button at the top of the screen.
As sequestration reductions have been imposed by the Centers for Medicare & Medicaid Services (CMS), Humana has implemented the same reductions to network and non-network provider payments. All non-network and network healthcare providers who are reimbursed using a fee schedule based on the Medicare payment system, percentage of Medicare Advantage premium or Medicare allowed amount (e.g., resource-based relative value scale [RBRVS], diagnosis-related group [DRG], etc.) will have the same sequestration reduction applied in the same manner as CMS. This reduction applies to all Medicare Advantage plans.
The sequestration reduction amount for each affected claim will be identified on the explanation of remittance healthcare providers receive from Humana. Questions may be directed to Humana provider relations by calling 1-800-626-2741, Monday – Friday, 8 a.m. – 5 p.m., Central time. Additionally, healthcare providers may refer to the , PDF opens new window for more information.
Billing for home health services
Providers of home health services to Humana Medicare Advantage plan members must use the ASC X12 837I ("Institutional") transaction (or, only when appropriate, the paper equivalent). The ASC X12 837I standard transaction is used by institutional healthcare providers, including home health agencies, to bill Original Medicare. Likewise, Humana's Medicare Advantage plans require providers to submit all charges for home health services using the 837I transaction standard. (In the rare case that a paper submission is appropriate, the plan will permit a provider to submit charges using the paper equivalent of 837I, which is Form CMS-1450, also known as UB-04).
A Humana Medicare Advantage plan will deny charges for home health services submitted using an 837P ("Professional") transaction standard or a paper CMS-1500 form because those formats are improper for home health services. In those cases, the provider may resubmit charges using an appropriate institutional format.
Additional CMS billing requirements for home health include, but are not limited to, the following:
- Submitting the home health resource group (HHRG) with revenue code 023
- Submitting the treatment authorization code (TAC), which is obtained through the Medicare OASIS system
- Submitting the core-based statistical area (CBSA) where services were rendered (submitted with value code 61)
- Using an appropriate home health prospective payment system (PPS) bill type
- Billing each visit on a separate claim line
- Billing each visit with the appropriate CMS-designated revenue and Healthcare Common Procedure Coding System (HCPCS) code combinations
- Billing units appropriate for the description of the HCPCS code (e.g., CMS visit G-codes represent 15-minute increments of service)
- Billing a claim line for nonroutine supplies (NRS) when the HHRG indicates NRS were provided
- Billing CMS-required informational Q-codes