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Humana Provider Payment Integrity Medical Record Review Dispute Policy

This policy only applies to disputes concerning Humana Provider Payment Integrity’s (PPI) medical record review findings made during the adjudication of a claim or post-payment review of a claim. Humana offers healthcare providers up to 2 opportunities to dispute Humana’s medical record review findings (Levels One and Two). Dispute requests are reviewed by licensed or certified personnel who were not the individuals who made the initial findings.

Please submit all levels of disputes to the following address or fax number:

Humana Provider Payment Integrity Disputes
P.O. Box 14279
Lexington, KY 40512-4279
Fax: 888-815-8912

To ensure proper routing and a thorough and timely review of your dispute, please include a copy of the completed Humana PPI Medical Record Review Dispute Request Form that was attached to the original findings letter and any other documentation related to your dispute.

Level One disputes will be reviewed by licensed or certified personnel appropriate for the claim type (certified coder, physician, registered nurse, pharmacist, etc.). These personnel are different from the individuals who made the initial findings and those who conduct Level Two reviews.

Level Two disputes must be submitted within 60 calendar days from the date of the Level One dispute determination letter. Level Two disputes may be reviewed by an independent and external third-party entity.

The third-party entity differs from those who conducted prior reviews. The entity is URAC-accredited with an expansive network of actively licensed medical doctors and coders certified by the American Academy of Professional Coders or the American Health Information Management Association.

Notwithstanding the foregoing, all disputes must be submitted within the specific time frames set out in any applicable contract or as otherwise required by applicable federal or state law.

Unless otherwise stated in the contract, an in-network qualified healthcare provider may submit a dispute request within 18 months from the receipt of the original claim determination. An out-of-network qualified healthcare provider may submit a dispute request within 180 days from the receipt of the original claim determination.

If a provider does not submit a written request to dispute the review findings or if their request is not received within the required time frame, the original review findings will be final.

* Click for details on Ohio Medicaid disputes involving a medical necessity determination

Humana Healthy Horizons® is a Medicaid product offered by affiliates of Humana Inc.

Level One

Level Two

Payment integrity & disputes