Humana (or its designee) conducts post-payment reviews of healthcare providers’ records related to services rendered to Humana members. During such reviews, the healthcare provider is asked to allow Humana access to the medical record and billing documents that support the charges billed.

The Treatment, Payment and Health Care Operations (TPO) exception under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule (45 CFR 164.506) allows the release of medical records containing protected health information between covered entities without an additional authorization for the purpose of payment and review of healthcare claims. Healthcare providers who believe that an additional release authorization for this review is necessary should obtain from Humana members their authorization for release of the medical records to Humana, along with the healthcare provider’s consent-to-treatment forms, or the requirement will be waived if permitted by law.

Humana utilizes, but is not limited to, the resources below to conduct its reviews. These are widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers. A healthcare provider’s order must be present to support all charges, along with clinical documentation to support the diagnosis and services or supplies that were billed.

• Centers for Medicare & Medicaid Services (CMS) guidelines as stated in Medicare manuals
• Medicare local coverage determinations and national coverage determinations
• All Humana policies, including medical coverage policies, Humana provider manuals, claims payment policies, Humana PPI Department policies published on Humana.com and code-editing policies
• National Uniform Billing Guidelines from the National Uniform Billing Committee
• American Medical Association Current Procedural Terminology (CPT®) guidelines
• Healthcare Common Procedure Coding System (HCPCS) rules
• ICD-10-CM Official Guidelines for Coding and Reporting
• American Association of Medical Audit Specialists National Health Care Billing Audit Guidelines
• Industry-standard utilization management criteria and/or care guidelines, including MCG care guidelines (formerly Milliman Care Guidelines): current edition on date of service
• UB-04 Data Specifications Manual
• American Hospital Association Coding Clinic Guidelines
• Social Security Act
• Food and Drug Administration guidance
• National professional medical societies’ guidelines and consensus statements
• Publications from specialty societies such as the American Society for Parenteral and Enteral Nutrition, American Thoracic Society, Infectious Diseases Society of America, etc.
• Department of Health and Human Services final rules, regulations and instructions published in the Federal Register
• Nationally recognized, evidenced-based published literature from such sources as:
  • UpToDate®
  • World Health Organization
  • Modified Framingham Criteria
  • Academy of Nutrition and Dietetics
  • American Society for Parenteral and Enteral Nutrition
  • Medscape
  • American Association for the Study of Liver Diseases
  • Society for Healthcare Epidemiology of America
  • Kidney Disease: Improving Global Outcomes, Clinical Practice Guideline for Acute Kidney Injury
  • The Third International Consensus Definitions for Sepsis and Septic Shock
  • Journal of the American Society of Nephrology (JASN)

Humana PPI post-payment reviews look for overutilization of services or other practices that directly or indirectly result in unnecessary costs to the healthcare industry, including the Medicare and Medicaid programs. Examples include, but are not limited to:

• Improper payment for services
• Payment for services that fail to meet professionally recognized standards/levels of care
• Excessive billed charges or selection of the wrong code(s) for services or supplies
• Billing for items or services that should not have been or were not provided based on documentation supplied
• Unit errors, duplicate charges and redundant charges
• Lack of sufficient documentation in the medical record to support the charges billed
• Experimental and investigational items billed
• Lack of medical necessity to support services or days billed
• Services billed are not covered per the member’s benefit plan, Humana policies, Medicare policies or Medicaid policies, such as National Coverage Determinations and Local Coverage Determinations
• Lack of objective clinical information in the medical record to support condition for which services are billed
• Items not separately payable or included in another charge, such as routine nursing, capital equipment charges, reusable items, etc.

These reviews also confirm that:

• The most appropriate and cost-effective services and supplies were provided.
• The records and/or documentation substantiate the setting or level of service that was provided to the patient.

On-site reviews

An on-site review allows a reviewer to visit a healthcare provider to review medical records and other billing documentation in person. Humana has the following on-site review guidelines:

• A representative for the healthcare provider may be present during the review process.
• Humana or its designee will notify the healthcare provider of the intent to review a claim.
• The healthcare provider will submit to Humana or its designee a copy of the itemized bill, if requested, within 30 days of the date requested. The bill should be submitted before the review occurs.
• Humana or the designee will contact the healthcare provider’s review representative to schedule the review. Healthcare providers are asked to respond to a scheduling request within 30 days of receipt of the request and schedule the review on a mutually agreed date and time.
  • An exit conference is intended to be a high-level overview of trends identified during the review. The exit conference is not a time for disputing claims. This time should be used to discuss claims that fall within the trends and, if time allows, certain examples can be presented.
• If a scheduled date is not confirmed by the healthcare provider within 30 days of the initial request, Humana or the designee will attempt to contact the facility via phone, email or letter. If there is still no response, two additional attempts will be made. If Humana or its designee is still unsuccessful at scheduling a date for the onsite review after these attempts, a technical denial may be issued; this may result in the claim being considered overpaid and recovery being initiated. Once the review has been scheduled, the technical denial will be reversed, and the claim will be repaid if it has been recouped.
• Humana or the designee will notify healthcare providers of the review results via letter or by conducting exit conferences within 30 days from the date Humana or its designee completes the review (or on an alternative agreed-upon date).
• The healthcare provider may have the right to dispute the results of the review. Please refer to the  Humana PPI Medical Record Review Dispute Policy .
• If an underpayment is identified during the review and the healthcare provider is owed payment by Humana, the healthcare provider may be asked to submit a corrected claim to receive additional reimbursement.

Desk reviews

A desk review allows the healthcare provider to submit medical record and billing documentation to Humana or its designee for the post-payment review. The desk review process includes the following steps:

• Humana may conduct reviews of claim payments within 18 months of the original date of payment or such other period as may be required or allowed by applicable law, or any Humana participation agreements.
• Humana may request medical records, itemized bills, invoices or other substantiating documentation to support the charges billed.
• Healthcare providers are asked to send copies of requested documentation within 30 days of receipt of the request.
• Information on payment for copying fees can be found in the  Humana PPI Medical Records Management Policy .
• Healthcare providers can submit requested documentation to Humana via mail, fax, upload or an electronic medical records system. For faster adjudication of claims, the requested information should be uploaded. Details on submission methods can be found in the  Humana PPI Medical Records Management Policy .
• In the event a healthcare provider does not submit or refuses to provide a medical record, he or she may receive a technical denial that may result in the claim being considered overpaid and recovery initiated. The  Humana PPI Technical Denial Policy  contains additional information.
• If an underpayment is identified during the review and the healthcare provider is owed payment by Humana, the healthcare provider may be asked to submit a corrected claim to receive additional reimbursement.
• If Humana determines that a coding and/or payment adjustment is applicable, the healthcare provider will be informed of the desk-review findings by a letter providing an explanation of any overpayment or underpayment. Healthcare providers may have the right to dispute results of reviews. Those who are not in agreement with the explanation or findings should refer to the  Humana PPI Medical Record Review Dispute Policy  for details.

PPI will not accept disputes after 18 months from the date the claim was paid, denied or not paid by the required date or as otherwise provided by state or federal law. The time frame for nonparticipating healthcare providers is 180 days when applicable state and federal laws are silent.

If a dispute request is initiated within 75 calendar days from the date of the findings letter, recoupment may be avoided until the dispute process is completed.

Records submission

Healthcare providers who do not submit the requested medical record documentation may receive a technical denial until all necessary information is received. Please refer to the  Humana PPI Technical Denial Policy  for details and time frames for submitting necessary information.