stethoscope

Join our network and find credentialing information.

Log in to Availity Essentials™ to access patient benefits, claims information and more.

Find tools and materials to support doing business with us.

Learn more about research and trends that impact your practice.

Find self-service info and phone numbers and update your provider data.

Review prior authorization lists for services, medications and submission guidance.

Prior authorization submission information

Professionally administered drugs prior authorization

Find appeals guidelines and payment policy information.

Learn how to submit claims and find coding guidance.

Find policies for procedures, devices and medications.

Review guidelines and health programs to support your patients and practice.

Find dental benefits, tools and resources.

Prior authorization for professionally administered drugs 

Locate state-specific resources for Humana Healthy Horizons® (Medicaid).

compass

Shop plans, learn about Medicare and explore member resources.

Search for in-network medical, vision, dental and pharmacy providers.

Humana Provider Payment Integrity Medical Record Review Requirements

Humana, or its designee, has the right to conduct reviews of healthcare providers’ records related to services rendered to Humana-covered patients in certain circumstances. Humana requests access to medical records and billing documents periodically to conduct reviews. Upon request, the healthcare provider should be able to provide detailed itemizations of charges to support the supplies and services billed.

For an overview of Humana's review processes, please refer to the Humana Provider Payment Integrity Post-payment Review Policy and the Humana Provider Payment Integrity Prepayment Review Policy.

The healthcare provider should include all records and/or documentation that substantiate the services provided to the patient and all information necessary to allow accurate adjudication of the claim. A healthcare provider who does not submit or refuses to provide a medical record may receive a technical denial for medical record documentation not received. Please refer to the Humana Provider Payment Integrity Technical Denial Policy and Humana Medical Record Types and Definitions for more information.

Types of records Humana or its designee may request include, but are not limited to, the following:

    Activities of daily living (ADL) sheet, including flow sheets and/or logs

    Admission assessments

    Anesthesia records (including time of anesthesia administration)

    Case management notes

    Change of therapy (COT) assessment

    Chat logs

    Chemotherapy orders

    Clinical trial information, including consents and treatment plans

    Consultation notes

    Diagnosis notes, including past medical history

    Discharge/transfer summaries

    Drawings and photos, when applicable

    Emergency department reports

    Evaluations: any evaluation related to the service provided

    Face sheets

    Face-to-face encounter documentation

    For durable medical equipment/home infusion/home health: delivery receipts or proof of delivery for supplies or drugs

    For inpatient rehabilitation: patient assessment instrument (PAI)

    For skilled nursing facilities: minimum data set (MDS)

    Hospice/end-of-life-care documentation

    Implant detail: sticker sheet and copies of invoices for implants or high-cost drugs; implant logs with additional information on implants, screws and plates

    Itemized bill

    Laboratory and pathology reviews: Clinical reviews of pathology claims often require additional information to make determinations. Medical records from the ordering physician, as well as the requisition form and lab results, are necessary to complete a full and fair review of the pathology claim. Please note that this documentation will be requested from the entity that submitted the pathology claim.

    Laboratory reports and X-rays from ordering physician, along with written interpretations of X-rays, tests and/or laboratory results

    Letter/certificate of medical necessity (CMN) for services

    Medication records/medication administration records (MAR), including strength, National Drug Code (NDC) and waste, mixing logs, infusion medication sheet and transfusion/infusion logs

    Nurse or any other healthcare provider’s progress, treatment, SOAP (subjective,objective, assessment, plan) notes, dietary notes and daily notes 

    Obstetric/newborn services

    Operating reports and records

    Operative reports

    Patient history

    Physical exam

    Physician office records: complete records, including office visit documentation, demographic/face sheet, patient history, laboratory and procedure results and all correspondence with healthcare providers, including consultation requests and reports

    Physician orders

    Plans of care (POC), treatment plans (tried and failed conservative treatments) and any related evaluations and updates or recertifications for the time period during which the patient was treated. The POC and recertifications should be signed by a qualified healthcare provider.

    Preanesthetic evaluation

    Preoperative and postoperative notes

    Prescriptions

    Progress notes

    Psychiatric evaluation notes

    Physician query (if applicable): If the facility’s coder requests additional information from the physician for clarification on documentation, he or she would submit a query to the physician.

    Skilled nursing, physical therapy, occupational therapy, speech therapy, respiratory therapy and medical social worker (MSW) documentation, including notes and therapy logs that detail the number of minutes each service was provided

    Test orders/results/reports including, but not limited to, pathology, radiology and laboratory (include results, when applicable)

    The Outcome and Assessment Information Set (OASIS) for home health claims, completed in its entirety. All six digits of the diagnosis code must exactly match between POC, OASIS and the claim. Any correction must be applied by the end of the episode. Fields cannot contain N/A, OASIS. Fields M2200 and M0110 cannot be blank or contain N/A.

    Toxicology reports

    Treatment notes

    Uniform billing form (UB-04)/Health Care Finance Administration Form (HCFA 1500)

    Wound care assessment



Payment integrity & dispute