Humana provider payment integrity policies and processes

At Humana, we strive 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

Manage overpayments online

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.

How to dispute Humana’s overpayment findings

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 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:

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 frame for each of Humana's products. Humana follows state regulations, provider contract requirements and CMS provisions when processing overpayments and recoupments.

Subrogation, Medicare secondary payer, and other payer liability

Use the Injury Report and File Status Request, PDF opens new window to:

  • Report accidents
  • Confirm if Humana provided benefits for an accident-related injury or illness
  • Request final payment information needed to settle claims made against other insurance carriers and individuals

Once you have completed the request, please email a saved copy to, or mail to:

Humana Subrogation and Other payer Liability
P.O. Box 2257
Louisville, KY 40201-2257

If you have additional questions or need to supply additional information, please contact us.