Humana operates a review program to detect, prevent and correct fraud, waste and abuse and to facilitate accurate claim payments. To further this program, Humana conducts reviews on prepayment and post-payment bases. Below you will find a description of the provider payment integrity (PPI) prepayment review process. Healthcare providers may have the right to dispute results of reviews.
Prepayment review process overview
Humana (or its designee) conducts prepayment reviews of healthcare providers' records related to services rendered to Humana members. During such reviews, the healthcare provider is asked to allow Humana access to medical records and billing documents that support the charges billed.
The Treatment, Payment and Health Care Operations (TPO) exception under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule (45 CFR 164.506) allows the release of medical records containing protected health information between covered entities without additional authorization for the payment of healthcare claims. Healthcare providers who believe that an additional release authorization for this review is necessary should obtain from Humana members their authorization for release of the medical records to Humana, along with the healthcare provider’s consent-to-treatment forms, or the requirement will be waived if permitted by law.
Humana utilizes, but is not limited to, the resources listed below to conduct its reviews. These are widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers:
- Centers for Medicare & Medicaid Services (CMS) guidelines as stated in Medicare manuals
- Medicare local coverage determinations and national coverage determinations
- All Humana policies, including but not limited to, medical coverage policies, provider manuals, claims payment policies, PPI Department policies published on Humana.com and code-editing policies
- National Uniform Billing guidelines from the National Uniform Billing Committee
- American Medical Association current procedural terminology (CPT®) guidelines
- Healthcare Common Procedure Coding System (HCPCS) rules
- ICD-10-CM Official Guidelines for Coding and Reporting
- American Association of Medical Audit Specialists National Health Care Billing Audit Guidelines
- Industry-standard utilization management criteria and/or care guidelines, such as MCG care guidelines (formerly Milliman Care Guidelines): current edition on date of service
- UB-04 data specifications manual
- American Hospital Association Coding Clinic Guidelines
- Social Security Act
- Food and Drug Administration guidance
- National professional medical societies' guidelines and consensus statements
- Publications from specialty societies, such as the American Society for Parenteral and Enteral Nutrition, American Thoracic Society, Infectious Diseases Society of America, etc.
- Department of Health and Human Services final rules, regulations and instructions published in the Federal Register
- Nationally recognized, evidence-based published literature including, but not limited to, sources such as:
- World Health Organization
- Modified Framingham Criteria
- Academy of Nutrition and Dietetics
- American Society for Parenteral and Enteral Nutrition
- American Association for the Study of Liver Diseases
- Society for Healthcare Epidemiology of America
- Kidney Disease: Improving Global Outcomes, Clinical Practice Guideline for Acute Kidney Injury
- The Third International Consensus Definitions for Sepsis and Septic Shock
- Journal of the American Society of Nephrology (JASN)
A healthcare provider’s order must be present to support all charges, along with clinical documentation to support the diagnosis and services or supplies that were billed.
Humana PPI prepayment reviews look for overutilization of services or other practices that directly or indirectly result in unnecessary costs to the healthcare industry, including the Medicare and Medicaid programs. Examples include, but are not limited to:
- Excessive billed charges or selection of the wrong code(s) for services or supplies
- Billing for items or services that should not have been or were not provided based on documentation supplied
- Unit errors, duplicate charges and redundant charges
- Insufficient documentation in the medical record to support the charges billed
- Experimental and investigational items billed
- Lack of medical necessity to support services or days billed
- Uncovered services per the member’s benefit plan, Humana policies, Medicare policies or Medicaid policies
- Lack of objective clinical information in the medical record to support condition for which services are billed
- Items not separately payable or included in another charge, such as routine nursing, capital equipment charges, reusable items, etc.
These reviews also confirm that:
- The most appropriate and cost-effective supplies were provided.
- The records and/or documentation substantiate the setting or level of service that was provided to the patient.
Reviews and records requests
Humana may conduct prepayment reviews of claims as required or allowed by applicable law and may request medical records, itemized bills, invoices or other substantiating documentation to support the charges billed. Healthcare providers are asked to send copies of requested documentation within 30 days of the request or within the appropriate federal and/or state guidelines. For information on payment for copying fees, please refer to your Humana participation agreement or the Humana PPI Medical Records Management Policy.
Healthcare providers can submit requested documentation to Humana via mail, fax, upload or an electronic medical records system. For faster adjudication of claims, the requested information should be uploaded. Details on submission methods can be found in the Humana PPI Medical Records Management Policy.
Healthcare providers who do not submit the requested medical record documentation may receive a technical denial, which will result in the claim being denied until all information necessary to adjudicate the claim is received. Please refer to the Humana PPI Technical Denial Policy for further details and time frames for submitting information.
If Humana or its designee determines that a coding and/or payment adjustment is applicable, the healthcare provider will receive the appropriate claim adjudication, an explanation of remittance (EOR) and a findings letter. Healthcare providers may have the right to dispute results of reviews based on explanation, findings or payments as stated in the Humana PPI medical record review dispute policy. Those who are not in agreement with the explanation or findings may refer to the Humana PPI Medical Record Review Dispute Policy for details.
PPI will not accept disputes for in-network providers 18 months from the date the claim was paid, denied or not paid by the required date or as otherwise provided by state or federal law. The time frame for out-of-network physicians and other healthcare professionals is 180 days when applicable state and federal laws are silent.