Humana Provider Payment Integrity Medical Record Review Resources
Humana’s provider payment integrity (PPI) unit focuses on ensuring that physicians and other health care professionals receive accurate payments for their claims. The unit also works to prevent fraud, waste and abuse. The resources below can assist those who interact with the PPI unit’s clinical audits team.
Inpatient to outpatient rebilling: Humana will consider reimbursement for services at an outpatient level when hospital services were appropriate, but reimbursement at the inpatient level is not appropriate. This policy provides guidance for the billing of an outpatient claim after a determination that an inpatient level reimbursement is not appropriate: Inpatient to outpatient rebilling policy (link opens in new window)
Itemized bill review: See a list of previous claim processing edits and other notifications related to the Itemized Bill Review for Inpatient Routine Services policy.
Medical record review dispute policy: Learn about the dispute resolution process for physicians and other health care professionals who disagree with Humana’s findings.
Medical record review requirements: See a list of records that may be requested.
Medical records management policy: Get details on submitting medical records to Humana’s provider payment integrity department.
Post-payment review policy: Find out about audit processes.
Prepayment review policy: Get an explanation of the prepayment review process.
Technical denial policy: Learn about the policy for denials that occur when a physician or other health care provider does not respond to a request for medical records from Humana.