Humana provider payment integrity medical record review requirements

Humana, or its designee, has the right to conduct reviews of physicians' and other healthcare providers' records related to services rendered to Humana-covered patients in certain circumstances. As stated in their participation agreements, healthcare providers will, upon request, grant Humana access to medical records and billing documents to conduct reviews. The healthcare provider should be able to provide detailed itemizations of charges to support the supplies and services billed.

For an overview of Humana's review processes, please refer to the Humana provider payment integrity policy for postpayment reviews and the Humana provider payment integrity policy for prepayment reviews.

The healthcare provider should include all records and/or documentation that substantiate the services that were provided to the patient and all information necessary to allow accurate adjudication of the claim. A healthcare provider who does not submit or refuses to provide a medical record may receive a technical denial. Please refer to the Humana provider payment integrity technical denial policy for more information.

Types of records Humana or its designee may request include, but are not limited to, the following:

  • Activities of daily living (ADL) sheet, including flow sheets and/or logs
  • Admission assessments
  • Anesthesia records (including time of anesthesia administration)
  • Case management notes
  • Change of therapy (COT) assessment
  • Chat logs
  • Chemotherapy orders
  • Clinical trial information, including consents and treatment plans
  • Consultation notes
  • Diagnosis notes, including past medical history
  • Discharge/transfer summaries
  • Drawings and photos, when applicable
  • Emergency department reports
  • Evaluations: any evaluation related to the service provided
  • Face sheets
  • Face-to-face encounter documentation
  • For durable medical equipment/home infusion/home health: delivery receipts for supplies or drugs/proof of delivery
  • For inpatient rehabilitation: patient assessment instrument (PAI)
  • For skilled nursing facilities: minimum data set (MDS)
  • Hospice/end-of-life-care documentation
  • Implant detail: sticker sheet and copies of invoices for implants or high-cost drugs; implant logs with additional information on implants, screws and plates
  • Itemized bill
  • Laboratory and pathology reviews: Clinical reviews of pathology claims often require additional information to make determinations. Medical records from the ordering physician, as well as the requisition form and lab results, are necessary to complete a full and fair review of the pathology claim. Please note that this documentation will be requested from the entity that submitted the pathology claim.
  • Laboratory reports and X-rays from ordering physician, along with written interpretations of X-rays, tests and/or laboratory results
  • Letter/certificate of medical necessity (CMN) for services
  • Medication records/medication administration records (MAR), including strength, National Drug Code (NDC) and waste, mixing logs, infusion medication sheet and transfusion/infusion logs
  • Nurse or any other healthcare provider’s progress, treatment, SOAP (subjective/objective assessment and plan), dietary notes and daily notes
  • Obstetric/newborn services
  • Operating reports and records
  • Operative reports
  • Patient history
  • Physical exam
  • Physician office records: complete records, including office visit documentation, demographic/face sheet, patient history, laboratory and procedure results and all correspondence with other healthcare providers, including consultation requests and reports
  • Physician orders
  • Plans of care (POCs), treatment plans (tried and failed conservative treatments) and any related evaluations and updates or recertifications for the time period during which the patient was treated. The POC and recertifications should be signed by a physician.
  • Preanesthetic evaluation
  • Preoperative and postoperative notes
  • Prescriptions
  • Progress notes
  • Psychiatric evaluation notes
  • Physician query (if applicable): If the facility's coder requests additional information from the physician for clarification on documentation, he or she would submit a query to the physician.
  • Skilled nursing, physical therapy, occupational therapy, speech therapy, respiratory therapy and medical social worker (MSW) documentation, including notes and therapy logs that detail the number of minutes each service was provided
  • Test orders/results/reports including, but not limited to, pathology, radiology and laboratory (include results, when applicable)
  • The Outcome and Assessment Information Set (OASIS) for home health claims: This must be completed in its entirety. All 6 digits of the diagnosis code must exactly match between POC, OASIS and the claim. Any correction must be applied by the end of the episode; fields cannot contain N/A, OASIS; fields M2200 and M0110 cannot be blank or contain N/A.
  • Toxicology reports
  • Treatment notes
  • Uniform billing form (UB-04)/Health Care Finance Administration Form (HCFA 1500)
  • Wound care assessment