Audit appeal

Humana Provider Payment Integrity Medical Record Review Dispute Policy

This policy only applies to disputes concerning Humana Provider Payment Integrity’s (PPI) medical record review findings made during the adjudication of a claim or post-payment review of a claim. Humana offers health care providers up to three opportunities to dispute Humana’s medical record review findings (Levels One, Two and Three).i Dispute requests are reviewed by licensed or certified personnel different from the individuals who made the initial findings.

Please submit all levels of disputes to the following address:

Humana Provider Payment Integrity Disputes

P.O. Box 14279

Lexington, KY 40512-4279

Fax: 1-888-815-8912

To ensure proper routing and a thorough and timely review of your dispute, please include a copy of the completed Humana PPI Medical Record Review Dispute Request Form (link opens in new window) that was attached to the original findings letter and any other documentation related to your dispute.

Post-payment recoupment: If the initial findings letter describes an overpayment made to your facility, and you wish to avoid recoupment and dispute the initial findings, you must submit a formal, written Level One dispute letter along with all relevant documents within 75 calendar days from the date of the findings letter. If recoupment has not been initiated by the time we receive your dispute, the overpayment is placed on hold so that monies are not recouped or offset from future payments until the dispute process is completed.

Level One

Level One disputes will be reviewed by licensed or certified personnel appropriate for the claim type (certified coder, physician, registered nurse, pharmacist, etc.). These personnel are different from the individuals who made the initial findings and those who conduct Level Two and Level Three reviews.

Level Two

Level Two disputes must be submitted within 60 calendar days from the date of the Level One dispute determination letter. Level Two disputes may be reviewed by an independent, external third-party entity. The third-party entity differs from those that conducted prior reviews and will not conduct the Level Three review. The entity is URAC-accredited with an expansive network of actively licensed medical doctors and coders certified by the American Health Information Management Association (AHIMA).

Level Three

Level Three disputes must be submitted within 60 calendar days from the date of the Level Two dispute determination letter. Level Three disputes may be reviewed by an independent, external third-party reviewer. The third-party entity differs from those that conducted prior reviews and is URAC-accredited with an expansive network of actively licensed medical doctors and coders certified by the American Health Information Management Association (AHIMA). Completion of a Level Three dispute exhausts internal administrative rights. In all cases, the Level Three reviewers will differ from individuals who conducted previous reviews.

Notwithstanding the foregoing, all disputes must be submitted within the specific time frames set out in any applicable contract or as otherwise required by applicable federal or state law. If you do not submit a written request to dispute the review findings or if your request is not received within the required time frame, the original review findings will be final.