Technical denial

Humana Provider Payment Integrity Technical Denial Policy

A technical denial is a denial of the entire paid amount of a claim in instances when the care provided to a member cannot be substantiated due to a health care provider’s non-response to Humana’s requests for medical records, itemized bills, documents, etc. If the requested documentation is received within 18 months of the technical denial issue date, the technical denial will be reversed and the claim will be reprocessed, provided that a review can occur and the claim can be properly adjudicated per the appropriate contractual, state or federal guidelines.

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 health care provider asking that records be provided within 30 days from the date of the letter.
  • Second reminder: Communication via telephone is made within seven business days after the initial request.
  • Explanation of remittance (EOR) notification: If the requested records are not received within the required time frame, the health care provider will receive an explanation of remittance, showing the full denial of the claim due to lack of documentation to substantiate the services billed and accurately adjudicate the claim.

Post-payment technical denials

For post-payment reviews, medical records and/or related documentation will be reviewed as outlined in the Humana Provider Payment Integrity Policy Post-payment Review Policy. The timeline for these requests is as follows:

  • Initial request: A letter will be mailed to the health care provider asking that records be provided within 30 days from the date of the letter.
  • Second reminder:  If the requested records are not received within 30 days of the initial letter, a second letter will be mailed to the health care provider, allowing an additional 30 days to respond.
  • Final notice: If the requested records are not received within 30 days of the second reminder, a final notice will be mailed to the health care provider, allowing an additional 30 days to respond.
  • Request for refund: If the requested records are not received within 30 days of the final notice, Humana will issue a technical denial, and the provider will receive a request-for- refund letter.

The health care provider will have 45 days from the date on the request-for-refund letter to send a refund check before the paid amount of the claim is recouped.

On-site reviews

In the case of an on-site review, Humana or Humana’s designee will contact the health care provider’s representative to schedule the review. Health care providers should respond to a scheduling request within 30 days of receipt of the request and schedule the review on a mutually agreed date and time. If a scheduled date is not confirmed by the provider within 30 days of the initial request, Humana or the designee will attempt to contact the facility via phone, email or letter. If there is still no response, two additional attempts will be made (30 days apart). If Humana or its designee is still unsuccessful at scheduling a date for the on-site review after these attempts, a technical denial may be issued for all review-related claims. Once the review has been scheduled, the technical denial will be reversed and the claims will be processed, providing that the scheduled date is within applicable contractual, state and/or federal guidelines.