The Humana Provider Payment Integrity (PPI) Department focuses on ensuring that healthcare providers receive accurate payments for their claims. The Humana PPI Department also works to prevent fraud, waste and abuse. The resources below can assist those who interact with the Humana PPI Department’s medical record review team.
, PDF opens new window: Humana will consider reimbursement for services at an outpatient level when hospital services were appropriate but reimbursement at the inpatient level is not appropriate. This policy provides guidance for the billing of an outpatient claim after a determination that an inpatient-level reimbursement is not appropriate.
Itemized bill review: See a list of previous claim processing edits and other notifications related to the Itemized Bill Review for Inpatient Routine Services policy.
Medical record review dispute policy: Learn about the dispute resolution process for healthcare providers who disagree with Humana's findings.
Medical record review requirements: See a list of records that may be requested.
Medical records management policy: Get details on submitting medical records to the Humana PPI Department.
Post-payment review policy: Find out about review processes.
Prepayment review policy: Get an explanation of the prepayment review process.
Technical denial policy: Learn about the policy for denials that occur when a healthcare provider does not respond to a request for medical records from Humana.
, PDF opens new window This form should be used when submitting a dispute.