Payment Policies

Humana claims payment policies

Humana is publishing its medical claims payment policies online as a new avenue of transparency for health care providers and their billing offices. This information about reimbursement methodologies and acceptable billing practices may help health care providers bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.

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This policy established how Humana plans reimburse charges for computer assisted surgery. Computer assisted surgery, also referred to as surgical navigation or image-guided surgery, provides surgeons with additional information and is used during procedures in which direct visibility is limited.
Published Date: 01/08/2019
This policy establishes how Humana plans reimburse the repair and replacement of durable medical equipment (DME) base items, parts and accessories.
Published Date: 12/14/2018
Telehealth is a method of delivering health care services via electronic information and telecommunications technologies.
Published Date: 06/26/2018
This policy outlines the criteria Humana plans use to determine the appropriate level of E/M service code facilities should report for care provided in the emergency department.
Published Date: 04/04/2018
Modifier JW identifies a drug amount discarded or not administered to any patient, as defined by the Centers for Medicare & Medicaid Services.
Published Date: 09/25/2017
Providers must append modifier FX to a procedure code for an X-ray service furnished using film.
Published Date: 08/29/2017
Original Medicare reimbursement for the technical component (TC) of CR X-ray services reported with the new modifier for CR X-ray services is reduced for dates of service in 2018 through 2022 by seven percent and for dates of service in 2023 and subsequent years by 10 percent. The CR X-ray reimbursement reduction is required for the Medicare Program by the Consolidated Appropriations Act of 2016.
Published Date: 08/29/2017
The timely filing, otherwise referred to as proof of loss, period is the time-frame from the date of service until the date by which a claim must be submitted to Humana to receive reimbursement for rendered covered services.
Published Date: 08/23/2017
This policy outlines multiple procedure payment reductions (MPPR) for therapy services, diagnostic cardiovascular, ophthalmology and imaging services. When the same provider renders multiple services, or multiple units of the same service, to the same patient on the same day, the total calculation for the procedure code(s) could account more than once for an input that was only rendered once. Examples include greeting and gowning the patient; preparing the room, equipment and supplies; providing education and obtaining consent. An MPPR adjusts reimbursement to offset duplication of reimbursement for inputs that were only rendered once.
Published Date: 03/29/2017
The Social Security Act requires charges for some Medicare Program services to be submitted with ordering or referring provider information from a qualified health care provider. This requirement ensures quality of care because many services require a qualified health care provider to interpret and provide guidance to the patient.
Published Date: 03/29/2017
The Department of Health and Human Services established a uniform definition of habilitative services and devices to help clarify the difference between rehabilitative and habilitative services and devices. This policy was previously titled "Habilitative Services and Devices"
Published Date: 12/29/2016
CMS has directed providers to use modifier CT to report computed tomography (CT) services furnished on equipment that is not consistent with dose optimization standards.
Published Date: 12/19/2016
This policy establishes the timeframes for a qualified healthcare provider submission of dispute requests.
Published Date: 11/30/2016
Modifier 53 is used when a physician terminates a surgical or diagnostic procedure because of extenuating circumstances or those that may threaten the well-being of a patient.
Published Date: 09/30/2016
This policy establishes Humana's reimbursement guidelines for provider-based clinic services.
Published Date: 09/22/2016
Providers can report condition code 45 or modifier KX with gender specific services provided to transgender and intersex members to allow them to be processed correctly.
Published Date: 08/30/2016
Humana expects suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) to retain proof of delivery (POD) documentation and make it available to Humana upon request. It is required to verify that our members received the billed equipment or supply.
Published Date: 07/18/2016
Facility billing guidelines for the UB-04 claim form, also known as the CMS-1450, and the 837 Institutional electronic equivalent require providers to bill revenue codes to describe services rendered.
Published Date: 06/24/2016
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.
Published Date: 06/16/2016
Current Procedural Terminology codes 99495 and 99496 were developed to report transitional care management (TCM). The codes recognize and reimburse physicians and qualified nonphysician practitioners for face-to-face and non-face-to-face services that are provided as part of care management for a member’s transition from a facility setting to the community or home setting.
Published Date: 05/11/2016
Pass-through billing occurs when an ordering provider requests and bills for a service, but the service is not performed by the ordering provider or individuals under the ordering provider’s direct employment. Sub-contracted individuals are not under “direct employment.”
Published Date: 02/25/2016
Modifier 78 is defined as an unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period.
Published Date: 12/31/2015
This policy outlines Humana’s billing requirements and reimbursement for CCM and complex CCM services.
Published Date: 03/31/2015
According to CMS, the initial preventive physical examination is a one-time introductory visit provided during the first 12 months a Medicare beneficiary has Part B benefits. If a beneficiary has had Part B benefits for longer than 12 months, the beneficiary can get an annual wellness visit.
Published Date: 03/24/2015
The Centers for Medicare & Medicaid Services (CMS) allows some physicians and practitioners to opt out of the Medicare Program for a period of two years.
Published Date: 03/09/2015
Humana requests that physicians and health care providers submit all HCPCS drug codes with their corresponding valid NDC.
Published Date: 02/25/2015
A list of commonly used CPT and HCPCS modifiers, and a high level presentation of how those modifiers are generally used for reimbursement.
Published Date: 02/03/2015
CMS introduced four new HCPCS modifiers, -XE, -XP, -XS and -XU. These modifiers are collectively known as “-X{EPSU} modifiers”.
Published Date: 01/14/2015
The AMA introduced new CPT codes for urine drug testing, and created new CPT codes to replace some therapeutic drug assay codes. CMS created HCPCS codes to replace the CPT therapeutic drug assay codes that the AMA is deleting.
Published Date: 12/24/2014
CPT code 77427 represents five sessions of radiation treatment management.
Published Date: 12/24/2014
Assistant at surgery services are those services rendered by physicians or nonphysician practitioners (NPP) who actively assist the physician in charge of performing a surgical procedure.
Published Date: 12/12/2014
The Neonatal Intensive Care Unit (NICU) provides continuous care to a critically ill neonate and involves many advanced technologies and interventions that are unique to the specialty area. These critically ill neonates can suffer from various medical conditions including congenital heart defects, neural tube defects, prematurity, respiratory distress, metabolic disorders, and difficulties with feeding and growth. NICU is comprised of four levels of care. Each level of care has a corresponding revenue code: Level 1, Level 2, Level 3 and Level 4.
Published Date: 12/01/2014
Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.
Published Date: 10/13/2014
Modifier EY is appended to a procedure code to indicate that there is no physician or licensed health care provider order for this item or service.
Published Date: 09/19/2014
A colonoscopy allows the physician to examine the lining of the entire large intestine by using a flexible, fiber optic instrument that is inserted through the anus. The test may reveal inflamed tissue, abnormal growths, and ulcers. However, it is most often used to look for early signs of cancer in the colon or rectum. Special instruments can be passed through the colonoscope to remove any polyps if needed.
Published Date: 09/19/2014
After-hours Current Procedural Terminology (CPT®) codes 99050-99060 can be billed in conjunction with an office visit to indicate services were provided outside regular business hours or resulted in a disruption to regularly scheduled office hours. This policy applies to professional services only. After-hours codes are not intended to replace the evaluation and management services codes.
Published Date: 07/01/2014
Modifier 22 may be added to a procedure code to indicate that the work required to provide a service was substantially greater than is typically required. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition or physical and mental effort required).
Published Date: 07/01/2014
According to the Centers for Medicare & Medicaid Services, an itemized statement is a listing of each service(s) or item(s) provided to a beneficiary. A statement that reflects a grouping of services or items (such as a revenue code) is not considered an itemized statement.
Published Date: 07/01/2014
According to the American Medical Association, “Modifier 50 is used to report bilateral procedures that are performed at the same operative session” (by the same physician). “Bilateral procedures are procedures typically performed on both sides of the body. The intent of this modifier is for it to be appended to the appropriate unilateral code as a one-line entry on the claim form indicating that the procedure was performed bilaterally.”
Published Date: 06/20/2014
Modifier 62: Two surgeons, neither surgeon acting as an assistant.
Published Date: 06/20/2014
The Centers for Medicare & Medicaid Services (CMS) define certain items as capped rental durable medical equipment (DME). In the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule, CMS identifies the category as “CR.”
Published Date: 06/20/2014
The Centers for Medicare & Medicaid Services (CMS) define certain items as “inexpensive” and “other routinely purchased” durable medical equipment (DME). In the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule, CMS identifies the category as “IN.”
Published Date: 06/20/2014
A transcutaneous electrical nerve stimulator (TENS) is a device that delivers electrical current through electrodes placed on the skin to decrease the patient's perception of pain by inhibiting nerve impulses and/or stimulating the release of endorphins.
Published Date: 06/20/2014
Payment for a procedure that has a global surgical package includes payment for preoperative, intraoperative and postoperative care, as well as payment for various related services, such as complications following surgery, postsurgical pain management and supplies. There are occasions when more than one physician provides services included in the global surgical package of a surgery.
Published Date: 06/20/2014