Medical records review

This page provides examples of circumstances in which Humana may require the submission of member medical records for review.

Procedures, services or processes that may require medical record review

  • Any service submitted with a procedure code that is not specific
  • Nonsurgical obesity services
  • Services related to growth hormone therapy
  • Pre-existing conditions
  • Physical therapy, speech therapy, occupational therapy
  • Chiropractic services (upon request)
  • Cognitive therapy and sensory integration
  • Low vision rehabilitation
  • Alternative medicine and related services (upon request)
  • Investigational/experimental procedures, drugs, devices, other supplies or services (Phase I, Phase II, Phase III and emerging/evolving technology or procedures)
  • Dental or oral maxillofacial services or procedures when submitted for coverage under a medical plan
  • Services related to patient management, coordination of care, crisis intervention, multidisciplinary assessment or other unique community/member support or therapy services
  • Services for which diagnosis and procedure do not match (upon request)
  • Musculoskeletal services (upon request)
  • Any service submitted with a modifier 22 appended
  • Request for reconsideration of a previously denied claim when preauthorization was required but for which no preauthorization is currently on file
  • Air ambulance services
  • Medicare risk adjustment activities
  • Special investigations
  • Quality improvement activities
  • Healthcare Effectiveness Data and Information Set (HEDIS®) data collection
  • Emergency room services
  • Infertility-related services
  • Bariatric surgery
  • Transplant services
  • Intravenously (IV) infused medications
  • Amniotic membrane transplantation
  • Capsule endoscopy
  • Any service submitted with a modifier 66 appended
  • Autism-related services
  • Prosthetic devices and services
  • Spinal fusion
  • Collection of missing diagnosis data
  • Verification of reported hierarchical condition categories (HCC) diagnosis codes
  • Response to Centers for Medicare & Medicaid Services (CMS) Risk Adjustment Data Validation (RADV) reviews and audit
  • Mail-order drug (MOD) A and MOD B services

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.

Medical record submission

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, the provider may elect to contact Humana to determine when medical records are required. You may also 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.

Submission options

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 log into Humana.com/providers. If you are not a registered user on our website and wish to sign up, select the green “Sign in or Register” link at the top right of the page, then choose “Register as a new user.” You can also access the tool through Availity.com.

For any assistance with registration or with using the MRM tool on the Humana or Availity websites, please contact the eBusiness deployment team by sending an email to Deployment@humana.com.

The MRM tool allows you to:

  • Decrease duplicate requests from Humana by using our automated consolidation software
  • Submit requested medical records quickly and securely online (in TIF or PDF format)
  • View the status of submissions
  • View completed and open/new requests
  • Submit medical records for many Humana departments, including claims (commercial, Medicare and HumanaOne®), grievance and appeals (G&A), special investigations unit (SIU), subrogation and more

If records can't be uploaded using Humana.com or Availity.com, please submit them in one of the following ways:

  • Secure fax to 1-866-305-6655. Please refer to the detailed instructions for fax transmissions found in the records request letter you received.
  • Mail to the following address:
    Humana Medical Records Management
    P.O. Box 14465
    Lexington, KY 40512

If you have questions about this information, please call 1-800-4HUMANA (1-800-448-6262).

Utilization management

Utilization management may be performed by contracted vendors, and they may also request medical records for review, based on the member's plan. If the vendor issues a utilization management decision, it will be honored by Humana, and no further records will be requested. If the vendor's request for medical records is not honored, the claim may not be paid.