Find Out More About Humana Policies That Affect Health Care Providers and Their Patients

Humana policies

Humana creates operating policies and procedures to help maintain a high level of service to its members and network physicians and other health care providers. Humana asks all health care providers to review the following with office staff members:

Clinical practice guidelines

Humana annually reviews and adopts clinical practice guidelines based on guidance from national organizations generally accepted as experts in their fields. These clinical practice guidelines are available here. Choose from the current list of clinical practice guidelines, which includes renal disease, diabetes, cardiovascular disease, preventive care, behavioral health and others. The specific links take you from Humana's site to the website of the organizations that issued the guidelines. For example, the chronic obstructive pulmonary disease (COPD) link connects to the website for the Global Initiative for Chronic Obstructive Lung Disease. Paper copies of the guidelines also may be requested from your local market office or your local market provider relations representative.

Humana case management and chronic care programs

Humana offers a variety of programs for members who need care for complex medical situations or support for chronic conditions. Through these programs, care managers collaborate with physicians and other health care providers to help members continue to live at home safely while addressing their physical, behavioral, cognitive, social and financial needs.

Members who enroll in a Humana case management or chronic care program are assigned a care manager who supports them by phone (eligible members also receive home visits). The manager's goal is to anticipate members' needs and problems, encourage preventive care and prevent costly interventions. This is accomplished through home-safety assessments and evaluations of medical, functional and psychosocial status.

Some chronic conditions addressed by Humana programs include chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, hypertension, HIV/AIDS, asthma and diabetes.

Humana case management and chronic care programs are available for select Medicare, Medicaid, commercial, health care exchange and administrative-services-only members in all markets, except Puerto Rico.

Information about available care management programs and procedures for accessing services are available here and in the Provider Manual.

Members' rights and responsibilities

All Humana members have certain rights and responsibilities when being treated by Humana-contracted physicians. These rights are outlined in Humana's Rights and Responsibilities statement. Humana asks participating physicians to display a copy of the Rights and Responsibilities statement in their offices. Physicians can find a copy of the statement in the Provider Manual. Physicians also can obtain a printed copy of the manual by calling provider relations at 1-800-626-2741, Monday through Friday, 8 a.m. to 5 p.m. Central time.

Quality improvement (QI) program

Humana has a comprehensive quality improvement program that encompasses clinical care, preventive care and administrative functions of the health plan. Information about Humana's quality improvement program and progress toward goals is available here. For a written copy of the QI Program Description or a progress report of how goals are being met, mail a request to the following address:

Quality Operations Compliance and Accreditation Department-QI Progress Report

321 W Main St., WFP 20

Louisville, KY 40202

Utilization management

The utilization management program helps guide Humana members toward appropriate and cost-effective treatment options. It is important that physicians, other health care providers and Humana members know the following about the program:

  • Humana does not reward health care providers or other individuals for denying service or care.
  • UM decision-making is based only on appropriateness of care and service, and existence of coverage.
  • Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.
  • Physicians can obtain a copy of specific UM criteria by calling 1-800-448-6262, Monday through Friday, 8 am to 8 pm Eastern time.

Adverse determinations/denial decision

If a member receives an adverse determination or denial, his or her attending physician or primary care physician (PCP) may request to discuss the decision with a Humana medical director or pharmacist reviewer. A peer-to-peer conversation may be scheduled by calling the number in the denial notification letter. If another opinion is needed, an external review organization’s (ERO’s) board-certified specialist may be consulted.