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 (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
- The Healthcare Common Procedure Coding System (HCPCS) rules
- 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.