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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).

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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 Resources

The Humana Provider Payment Integrity (PPI) Department focuses on ensuring that healthcare providers receive accurate payments for their claims. The Humana PPI Department also works to prevent fraud, waste and abuse. The resources below can assist those who interact with the Humana PPI Department’s medical record review team.

Inpatient to outpatient rebilling: Humana will consider reimbursement for services at an outpatient level when hospital services were appropriate but reimbursement at the inpatient level is not appropriate. This policy provides guidance for the billing of an outpatient claim after a determination that an inpatient-level reimbursement is not appropriate.

Itemized bill requests: See a list of previous claim processing edits and other notifications related to the Itemized Bill Review for Inpatient Routine Services policy.

Medical record review dispute policy: Learn about the dispute resolution process for healthcare providers who disagree with Humana's findings.

Medical record review requirements: See a list of records that may be requested.

Medical records management policy: Get details on submitting medical records to the Humana PPI Department.

Post-payment review policy: Find out about review processes.

Prepayment review policy: Get an explanation of the prepayment review process.

Technical denial policy: Learn about the policy for denials that occur when a healthcare provider does not respond to a request for medical records from Humana.

Forms

Humana PPI Medical Record Review Dispute Request Form This form should be used when submitting a dispute.

Payment integrity & disputes