Humana provider payment integrity policies and processes

Common reasons for overpayments include, but are not limited to:

• An issue regarding the coordination of member benefits
• Medical record reviews
• Member plan termination
• Subrogation
• Duplicate payments
• Medical coding reviews
• Incorrect provider reimbursement
• Fraud, waste and abuse detection

The overpayments application on the Availity Portal helps you manage overpayments. You can:

• Reduce overpayment resolution time by managing overpayment requests from multiple payers in one app.
• View overpayment inventory in real time and assign related tasks to specific users.
• Manage overpayment documentation and maintain case histories electronically.
• Sign up to be notified when you have a new overpayment.
• Request more information about or dispute an overpayment request.

The overpayments application is located on the Availity Portal under “Claims & Payments.” If you do not see the application, ask your organization’s Availity administrator to grant you the “Claim Status” role.

Learn the key advantages and steps for getting started with the overpayments application in this informational flyer, PDF opens new window. For more detailed instructions about how to manage your overpayments using the application, review Availity’s user guide for Humana providers, opens new window.

The most efficient way to dispute an overpayment is to use the overpayments application on the Availity Portal. To get started:

• Access the overpayments application on the Availity Portal at Availity.com under “Claims & Payments.”
• In the application, click the action menu on the card for the overpayment you wish to dispute.
• Select “Dispute Overpayment.”
• In the “Dispute Overpayment” window, select a dispute type and enter a description of the dispute. You must provide a description of the dispute.
• Click “Submit.”

Alternatively, you can follow this dispute process:

• To dispute a medical record review – View the medical record review dispute policy and link to the medical record review dispute form.
• To resolve recoupment concerns, PDF opens new window – View information regarding general inquiries and the escalation process to resolve recoupment concerns, such as overpayments, financial recovery reviews, disputes and medical record requests.

These resources can help when you are interacting with PPI’s medical record review team.

Once a claim has been identified as overpaid, Humana may send a written notice of overpayment within the applicable time frame for each of Humana's products. Humana follows state regulations, provider contract requirements and CMS provisions when processing overpayments and recoupments.