Humana provider payment integrity policies and processes

Humana strives to offer our members high-quality healthcare at affordable rates. To achieve this goal, Humana provider payment integrity (PPI) reviews Humana’s claims payments for accuracy and requests refunds if claims are overpaid or paid in error.

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

How to dispute Humana’s overpayment findings

If you wish to dispute an overpayment, please follow the appropriate process as outlined below:

  1. To dispute a medical record review – View the medical record review dispute policy and link to the medical record review dispute form.
  2. 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.

Medical record review resources

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

PPI overpayment and recoupment

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