Note Changes to Claims Processing for Unauthorized Hospital Inpatient Services

Compliance training

Claims with both unauthorized hospital inpatient services and urgent/emergent services for a Humana-covered Medicare Advantage member are now placed in a pended status, instead of being automatically denied. Humana will hold the claim in pended status for up to 51 days from the date the claim was received. If an authorization is not submitted in that time or a new claim is not received, then the entire claim will not be covered.

A letter will alert the hospital that the inpatient services were not authorized. The letter requests that the hospital submit the patient’s medical records to receive authorization or submit a new claim for the urgent/emergent services without the unauthorized inpatient services.

Authorization tips

  • Hospitals are asked to request and receive authorization for inpatient admission before submitting an inpatient claim.
  • If authorization was not requested prior to inpatient admission or if authorization was requested, but denied, the hospital may submit medical records that support the inpatient admission. Humana will review the records to determine whether the admission was appropriate.
  • If Humana determines that the inpatient admission was appropriate, then the original claim will be removed from pended status and will process as usual.
  • If Humana determines that the inpatient admission was not appropriate, then the hospital may submit a claim for only the urgent/emergent and related ancillary services.
  • Hospitals may follow Centers for Medicare & Medicaid Services (CMS) billing guidelines to:
  • Submit a claim for outpatient preadmission services.
  • Submit a claim for post-admission services.

For more information, hospitals, physicians and other health care providers can call 1-800-448-6262, Monday through Friday, 8 a.m. to 8 p.m. Eastern time.