Payment integrity

At Humana, we strive to offer our members high-quality healthcare at affordable rates. To achieve this goal, the Humana Provider Payment Integrity (PPI) department reviews claims payments for accuracy and requests refunds if claims are overpaid or paid in error.

Common reasons for overpayment include:

An issue regarding the coordination of member benefits
Duplicate payments
Fraud, waste and abuse detection
Incorrect provider reimbursement
Medical coding reviews
Medical record reviews
Member plan termination
Subrogation

If you are not satisfied with Humana’s policies and procedures or a decision made by Humana that does not impact the provision of services to members, you may file a provider complaint. The provider complaint system consists of two internal steps:

Reconsideration: The first step in the provider complaint system, a reconsideration represents your initial request for an investigation into a denied claim, Humana Healthy Horizons’ policies and procedures, findings of a PPI audit, or the termination of a provider agreement. Most issues are resolved at the reconsideration step.
Formal appeal: The second step in the process; if a provider disagrees with the outcome of the reconsideration, an additional review known as a formal appeal can be made.

Claims overpayments

Providers must report to Humana Healthy Horizons all service claim overpayments for medical services rendered to Humana Healthy Horizons in Florida managed care plan members, in accordance with Humana’s contract with the Florida Agency for Health Care Administration (AHCA), within 60 days of identification of the overpayment. Regardless of agreement specifics, the provider or subcontractor must submit such claims after the date on which the overpayment was identified and notify Humana Healthy Horizons in writing of the reason for the overpayment, as required by 42 CFR 438.608.

Refund checks for overpayments can be mailed to:

Humana Healthcare Plans
P.O. Box 931655
Atlanta, GA 31193-1655

Humana Healthy Horizons reports all overpayments to AHCA Program Integrity. These reports include all unsolicited provider refunds.

Availity Essentials

Florida Medicaid