Back To Claim Processing Edits
Edits associated with new or revised American Medical Association (AMA) Current Procedural Terminology (CPT®), International Classification of Diseases (ICD), modifier and Healthcare Common Procedure Coding System (HCPCS) codes will be added.
In order to adjudicate claims accurately and in a timely manner, Humana will identify inappropriately coded claims and, when possible, reimburse using the correct code. Humana will do so based only on facts known to Humana, such as the age and gender of the member. For example, if Humana’s records indicate the age of the member does not match the description of the CPT code, the claim will be considered based on the CPT code that properly reflects the member’s age. If a claim is submitted for CPT code 42825 (tonsillectomy, primary or secondary; younger than age 12) and the member is 15 years old, that code will be denied, and CPT code 42826 (tonsillectomy, primary or secondary; age 12 or over) will be added to the claim. When the correct code cannot clearly be identified, the claim will be returned to the health care provider for correction and resubmission, if applicable.
Edits for CPT, ICD, modifier and HCPCS codes deleted by the AMA and/or CMS will be removed.
As noted in the AMA CPT manual, procedure codes that are designated add-on codes are intended to report additional service beyond the related primary code. The add-on code must be reported in conjunction with a related primary code. Therefore, add-on codes will not be reimbursed when the primary code is absent or has been denied for other reasons.
As supported by Section 1815(a) and Section 1833(e) of the Social Security Act, Section 422.214(a)(2) of Title 42 of the Code of Federal Regulations, contract provisions and other relevant guidance, Humana reserves the right to request itemized bills in order to confirm proper billing, prior to payment, when necessary. Any improper billing may result in payment reduction or denial for specific charges.
Claims may be denied if diagnosis codes are not coded to the highest specificity; diagnosis codes are incomplete; or diagnosis codes are invalid.
Humana does not reimburse for noncovered services (experimental and investigational, cosmetic, etc.) billed on facility claims. Noncovered services are listed in Limitations and Exclusions.
Humana expands incidental/bundling editing on a continuous basis.Updates are made to Humana’s editing systems based on direction from the AMACPT, the National Correct Coding Initiative (NCCI) and other applicable codingstandards.
Services will be reimbursed only when all diagnosis codes submitted on the claim are coded to the highest level of specificity.
Humana is committed to remaining consistent with CMS claims processing guidelines. To further that effort, as Medicare payment policies change, Humana continuously updates code-editing logic on all Humana Medicare Advantage (MA) products. Health care providers must follow applicable claim submission guidelines, including local coverage determinations (LCDs) and national coverage determinations (NCDs), to facilitate accurate claims processing results.
Humana is continuing to automate its medical coverage policies. Our claim code-editing logic will be updated to include the diagnosis and procedure codes that are covered per our policies. Procedure codes and/or diagnosis codes not allowed per our policies will not be reimbursed. For a complete list of medical coverage policies, please visit Humana.com/provider and choose “Medical and Pharmacy Coverage Policies” under “Resources.”
Per Humana’s provider contract language, claims shall include the physician’s national provider identifier (NPI) and the valid taxonomy code that most accurately describes the health care services reported on the claim. Submitting this information on claims will allow more accurate and timely processing of claims through Humana’s systems.
Procedures that are submitted in a manner that is not consistent with its definitions will not be reimbursed. For example, cesarean delivery only (59514) or cesarean delivery only including postpartum care (59515) will not be reimbursed when billed with routine obstetric care including antepartum care, cesarean delivery and postpartum care (59510). Based on the definition of 59510, it would not be appropriate also to bill 59514 or 59515, as the services represented by those codes are already included in 59510.
For California health care providers, this notification does not affect any contractual relationship you may have with a contracted independent physician association (IPA) for a Humana MA HMO product. This notification solely pertains to your participation with Humana under your ChoiceCare Network contract.
Humana expands incidental/bundling editing on a continuous basis. Updates are made to Humana’s editing systems based on direction from the American Medical Association (AMA), Current Procedural Terminology (CPT), the National Correct Coding Initiative (NCCI) and other applicable coding standards.
On nonfacility claims, professional supplies that are typically associated with a surgical procedure will not be separately reimbursed when submitted on the same date of service or within the allotted global period (0, 10 or 90 days).
Claim lines submitted with an unlisted or not otherwise classified code must be submitted with a description of services provided; claim lines submitted without a description, with a generic description or with an incomplete description may be denied.