2014 formularies

Humana updates dispute process and limitations

Humana adjudicates a claim for services provided to a plan member based on the information submitted in that claim and information related to that claim. If a physician or health care provider disagrees with Humana’s adjudication of that claim based on the information submitted, that physician or health care provider may submit a written request that includes new supporting clinical information for a dispute review of the plan’s determination. The request may be mailed to:

  • Humana Correspondence
  • P.O. Box 14601
  • Lexington KY 40512

Please note the following limitations, as they help ensure that any request for a dispute review receives the proper consideration:

  • When a charge for a service is denied after a medical necessity review, an in-network physician or health care provider may submit up to two dispute requests per claim.
  • A request for a dispute review needs to be submitted in writing, in a timely manner.
  • A request for a dispute review needs to be submitted with all required information.
  • Humana will review the claim to determine whether to revise the adjudication.
  • To ensure that new information submitted is fully considered, the in-network physician or health care provider needs to indicate clearly on the cover sheet accompanying the request which information is new and where it can be found within the submission. Also, the new information needs to be clearly highlighted or marked within the submission.

For more information, please review Humana’s claims payment policy by entering “claim disputes” in the search box

Questions may be directed to Humana provider customer service by calling 1-800-457-4708, 8 a.m. to 8 p.m. Eastern time, Monday through Friday.