Prepayment review technical denials
For prepayment reviews, medical records and/or related documentation will be reviewed as outlined in the Humana provider payment integrity prepayment review policy. When additional documentation is needed for Humana to accurately adjudicate the claim, the claim will be pended until the documentation is received or until the deadline for receipt of the documentation passes.
- Initial request: A letter will be mailed to the healthcare provider asking that records be provided within 30 days from the date of the letter.
- Second reminder: Communication via telephone is made within 7 business days after the initial request.
- Explanation of remittance (EOR) notification: If the requested records are not received within the required time frame, the healthcare provider will receive an EOR showing the full denial of the claim due to lack of documentation to substantiate the services billed and accurately adjudicate the claim.