Provider Manual

Revised Provider Manual Available Now, Effective Oct. 21, 2013

A revised version of Humana's Provider Manual is now available and will be effective on October 21, 2013. It was last updated in 2010. It's important for all contracted health care providers and administrators to review the new Provider Manual, as your participation agreement with Humana or ChoiceCare Network contains a compliance obligation with the provisions of this Manual.

Overall, the Provider Manual has been reorganized and streamlined to make it more user friendly. Similar subjects have been grouped together to help providers quickly locate the information they need. For example, the "Claims Procedures" section now includes information on both utilization management and referrals.

Additional notable revisions in this edition include the following:

  • Restructuring of the "Grievance and Appeal" section to detail the specific characteristics of: 1) member grievance/appeals, 2) provider claims reconsiderations and 3) provider termination appeals.
  • New language outlining obligations for any and all providers who submit a claim or encounter to Humana that generates a lab test result requiring the provider to submit the corresponding lab result electronically to Humana within 30 days of the member's date of service. This information is critical to Humana's advancement of its quality management and improvement programs, along with provider rewards initiatives. Keep in mind, payments will not be immediately impacted on the effective date of the revised provider manual; Humana will contact providers before there is financial impact. Until contacted, providers need not make any change to what they are doing today.
  • Additional language to describe health care providers' contractual obligations to report demographic changes (e.g., name, number, address, new physicians) quickly to Humana. This information confirms that Humana's network filings are accurate and provider communications can be shared effectively.
  • Addition of a new "Compliance/Ethics" section that covers liability insurance; fraud, waste and abuse requirements; notification requirements; conflicts of interest and Medicare obligations.

Requests for printed versions of the manual may be directed to Humana via email to or fax to 1-800-626-1686. Requests must include the name of the provider business, the name of person to receive the manual and the complete address.