Medical records review
This page provides examples of circumstances in which Humana may require the submission of member medical records for review.
This is not an all-inclusive list and it is subject to change. There may be additional occasions when medical records will be requested to validate a claim or coverage.
Physicians who want to submit medical records with a claim may use the list above as a guide. If required medical records are not received, they will be requested at the time claims are received. There may be an associated delay in claims payments.
The submission of medical records is not a guarantee of payment. All plan provisions still apply, and services not covered by the member's plan will not be paid.
Note: The need to submit medical records may be dependent on the member's plan. Since not all plans have the same requirements or coverage, you may contact Humana to determine when medical records are required. You also may wish to review our medical coverage policies page to learn about the evaluation and coverage of medical procedures and devices that are being investigated or have been recently introduced. State law may limit the ability to delay or deny payment on a claim based on a lack of medical records.
Humana's Medical Records Management (MRM) tool enables seamless, real-time sharing of medical record information between health care providers and the requesting Humana departments.
To view medical records requests and submit medical records through the MRM tool, please use the Availity Provider Portal. If you are registered for the Humana.com secure provider portal, you can access the MRM tool from the “Medical Records” tab. However, Humana is transitioning to the Availity Portal for online transactions. Once that transition is complete in late 2018, you will need to use the Availity Portal to access the MRM tool.
The MRM tool allows you to:
If records can't be uploaded using Availity.com or Humana.com, please submit them in one of the following ways:
If you have questions about this information, please call 1-800-4HUMANA (1-800-448-6262).
Utilization management may be performed by contracted vendors who may request medical records for review, based on the member's plan. If the vendor's request for medical records does not receive a response, the claim may not be paid. If the vendor issues a utilization management decision, it will be honored by Humana, and no further records will be requested.