MRDRs, QI, UM – More than alphabet soup

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Humana creates operating policies and procedures to help maintain a high level of service to its members and network physicians and other healthcare professionals. Humana asks all healthcare professionals to review the following with office staff members:

Medical record documentation review

Humana Quality Operations Compliance and Accreditation conducts medical record documentation reviews (MRDRs) on an annual basis. The reviews monitor compliance with regulatory agencies. Good medical record keeping also helps promote quality of care delivered to members. The minimum passing score is 85 percent compliance with the guidelines, with a goal of 90 percent. These guidelines are available here for downloading and printing. Click on the PDF entitled “Medical record documentation review elements” under the list of additional resources.

Other areas of Humana also may request and review medical records for specific operational and compliance needs. Depending on their purpose, such reviews may examine additional or different medical record elements and use criteria other than that described here.

Clinical practice guidelines

Humana annually reviews and adopts clinical practice guidelines based on guidance from national organizations generally accepted as experts in their fields. These clinical practice guidelines are available here. The current list contains guidelines for renal disease, diabetes, cardiovascular disease, preventive care, behavioral health and other health issues. The specific links connect to the organizations that issued the guidelines. For example, the diabetes guideline link connects the user to the American Diabetes Association’s standards of care.

Humana case management and chronic care programs

Humana offers a variety of programs for patients who need care for complex medical situations or support for chronic conditions. Through these programs, care managers collaborate with physicians and other healthcare professionals to help patients continue to live at home safely while addressing their physical, behavioral, cognitive, social and financial needs.

Patients who enroll in a Humana case management or chronic care program are assigned a care manager who supports them by phone. Eligible members also receive home visits. The manager’s goal is to anticipate patients’ needs and problems, encourage preventive care and prevent costly interventions. This goal is accomplished through home-safety assessments and evaluations of patient medical, functional and psychosocial status.

Some chronic conditions addressed by Humana programs include chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, hypertension, HIV/AIDS, renal disease, asthma and diabetes.

Humana case management and chronic care programs are available for patients with select Medicare, Medicaid, commercial and administrative-services-only coverage in all markets, except Puerto Rico.

Information about available care management programs and procedures for accessing services is available here and in the Provider Manual. Additionally, healthcare professionals may call the Humana Health Planning and Support team for assessment and referral to appropriate clinical program(s) at 1-800-491-4164, Monday through Friday, 8:30 a.m. to 5 p.m. local time.

Members’ rights and responsibilities

All Humana members have certain rights and responsibilities when being treated by Humana-contracted healthcare professionals. These rights are outlined in Humana’s Rights and Responsibilities statement. Humana asks participating healthcare professionals to display a copy of the Rights and Responsibilities statement in their offices. A copy of the statement is available in the Provider Manual. A printed copy of the manual can be obtained by calling provider relations at 1-800-626-2741, Monday through Friday, 8 a.m. to 5 p.m. Central time.

Quality improvement (QI) program

Humana has a comprehensive quality improvement program that encompasses clinical care, preventive care, population health management and the health plan’s administrative functions. To receive a written copy of Humana’s quality improvement program and its progress toward goals, submit a request to the following address: Quality Operations Compliance and Accreditation Department – QI Progress Report
321 W. Main St., WFP 20
Louisville, KY 40202

Utilization management (UM)

The utilization management program helps guide patients with Humana coverage toward appropriate and cost-effective treatment options. It is important that physicians, other healthcare professionals and their patients know the following about the program:

  • Humana does not reward healthcare professionals or other individuals for denying service or care.
  • UM decision-making is based only on appropriateness of care and service and existence of coverage.
  • Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.

Physicians can obtain a copy of specific UM criteria by calling 1-800-448-6262, Monday through Friday, 8 a.m. to 8 p.m. Eastern time.