Humana Provider Payment Integrity Denial for Lack of Medical Records Policy

A denial for lack of medical records is a denial of the entire billed or paid amount of a claim when the care provided to a member cannot be substantiated due to a healthcare provider’s lack of response to Humana’s requests for medical records, itemized bills, documents, etc.

If the requested documentation is received from a participating provider within 18 months of the denial for lack of medical records issue date, the denial for lack of medical records will be reversed and the claim will be reprocessed, provided that a review can occur and the claim can be properly adjudicated per the appropriate contractual, state or federal guidelines.

Documentation requested from nonparticipating healthcare providers must be received within 180 days (unless applicable state and federal laws specify a different time frame).

For prepayment reviews, medical records and/or related documentation will be reviewed as outlined in the Humana Provider Payment Integrity Prepayment Review Policy. When Humana needs additional documentation to adjudicate the claim, the claim will be pended until the documentation is received or until the deadline for receipt of the documentation passes.

Initial request: A letter will be mailed to the healthcare provider asking that records and/or additional documentation be provided within 30 days from the date of the letter.

Additional outreach attempts: If medical records and/or related documentation are not received within the first 20 days of allotted time frame allowed, a second request will be mailed to the provider requesting that the records and/or documentation be provided within 30 days from the date of the initial request letter.

Explanation of remittance (EOR) notification: If the requested medical records are not received within the required time frame, the healthcare provider will receive an EOR showing the full denial of the claim due to lack of documentation to substantiate the services billed.

Post-payment review denials for lack of medical records

For post-payment reviews, medical records and/or related documentation will be reviewed as outlined in the Humana Provider Payment Integrity Post-payment Review Policy.

Initial request: A letter will be mailed to the healthcare provider asking that records be provided within 45 days from the date of the letter.

Final notice: If the requested records are not received within 45 days of the initial request, a final notice will be mailed to the healthcare provider, allowing an additional 45 days to respond.

Request for refund: If the requested records are not received within 45 days of the final notice, Humana will issue a denial for lack of medical records, and the healthcare provider will receive a request-for-refund letter.

The healthcare provider will have 45 days from the date on the request-for-refund letter to send a refund check before the paid amount of the claim is recouped.

Post-payment on-site reviews

In the case of an on-site review, Humana or Humana’s designee will contact the healthcare provider’s representative to schedule the review. Healthcare providers should respond to a scheduling request within 30 days of receipt of the request and schedule the review for a mutually agreed date and time. If a scheduled date is not confirmed by the provider within 30 days of the initial request, Humana or its designee will attempt to contact the healthcare provider via phone, email or letter. If there is still no response, two additional attempts will be made (30 days apart). If Humana or its designee is still unsuccessful at scheduling a date for the post-payment on-site review after these attempts, a denial for lack of medical records may be issued for all review-related claims. Once the review has been scheduled, the denial for lack of medical records will be reversed and the claims will be processed, provided that the scheduled date is within applicable contractual, state and/or federal guidelines.

Denial for Lack of Medical Records Policy

Prepayment review denials for lack of medical records

Payment integrity & disputes