Doing Business with Humana Information for healthcare providers and administrators
Presentation Overview Credentialing/Recredentialing 1. Claims Inquiry Resolution Process and Code Edit Inquiries 2. Provider Payment Integrity (Financial Recovery) 3. Most Common Denial Reasons 4. Preauthorization and Notification Guidelines 5. Physician Finder Plus 6. Online Tools – Making it Easy 7. eBusiness/Availity 8. Key Points of Contact 9. 2
Credentialing Overview 3
Initial Credentialing The market contractors submit a task (via our workflow system) to add a provider or facility to • Humana’s network. The contractor will indicate on that task, if credentialing is needed. As well as attach a completed credentialing application or the providers CAQH #. If Credentialing is needed, a credentialing task will be created and sent to the credentialing team. • The credentialing team has a 7 day Service Level Agreement (SLA) for physicians and 2 day SLA for • facilities. The Credentialing team will review the credentialing application to ensure all required elements are present. If the required elements are present, the credentialing team will complete the provider/facility credentialing. A letter is sent to the • provider/facility advising their credentialing was approved. If the required elements are not present, the credentialing team will deny the provider/facility credentialing. An automatic • notification from our workflow system is sent to the market contractor that submitted the task, to advise them that credentialing was denied and what information they need to obtain for credentialing to complete the provider/facilities credentialing. Some situations require a provider to be taken to our committee board for review and determination as • to whether the providers credentialing can be approved. Reasons for taking a provider to committee are, but not limited to: Licenses with current material limitations, Adverse reactions indicated on the providers NPDB report, Restricted DEA/CDS, etc. 4
Recredentialing Providers and Facilities are required to be recredentialed every 3 years (unless their state mandates • recredentialing more frequently). Humana will initiate the provider/facilities recredentialing 7 months prior to their recred due date. This • allows plenty of time for the credentialing team to make multiple outreach attempts (phone calls, faxes and mailings) to collect the needed information to complete recredentialing. Note: Providers using CAQH – As long as they’ve re-attested within the last 120 days, and there isn’t any expired • information, we can complete their recredentialing without any outreach attempts to the provider needed. Providers not using CAQH and facilities, are required to complete a new credentialing application for their • recredentialing to be processed. Providers and facilities still missing information 60 days prior to their recred due date are sent to the • market contractors. The contractors then attempt to collect the needed information. Providers and facilities still missing information 30 days prior to their recred due date are sent a certified • letter, advising them that if the completed credentialing application/missing information is not provided in the next 30 days, they will be decredentialed. 5
Recredentialing, continued Providers and facilities still missing the required information to complete their recredentialing, at • their recred due date, are then decredentialed and removed from Humana’s network. Providers and facilities successfully recredentialed receive a letter from Humana, notifying them • that they’ve successfully been recredentialed. Providers and facilities that are decredentialed are sent a letter from Humana and the market contractors are notified of all decredentialed and therefore termed providers and facilities as well. The same reasons a provider may need to go to the committee board during the initial • credentialing process, may result in a provider being taken to the committee board at recredentialing as well. For example: A provider could have limitations placed on their licenses after they were initially credentialed. This would require the committee board to review the provider information and make the determination as to the providers recredentialing being approved or denied. 6
Claims 7
Claim Submission Time Frames • Claim submission time frames – Medicare Advantage: One (1) calendar year from date of service – Commercial: Generally must be submitted within: • 180 days from the date of service for physicians • 90 days from the date of service for facilities and ancillary providers • Please reference your contract as these timeframes may differ 8
Claim Payment Inquiry Resolution Guide Step 1 1. Call Humana’s Provider Contact Center (PCC) at 1-800-448-6262. Our Provider Contact Center Agents are trained to answer many of your claims questions and can initiate contact with other Humana departments when further review or research is needed. • a. Note the reference number issued to you by the Provider Contact Center Agent, as it may be needed in the future. • b. You have the option to speak to a Provider Contact Center supervisor if you feel your concern is not being properly addressed. Based on availability, you will either be connected to a supervisor, or a supervisor will contact you within 48 hours of your request. • c. If the Provider Contact Center associate needs to have your dispute reviewed by another department, you will receive a letter from the Humana department that completes the additional review/research. You will be notified of the review via a corrected EOR or a letter explain why the claim was upheld within 30 to 45 days. Please allow us time to properly research and resolve your inquiry before contacting us again. 9
Claim Payment Inquiry Resolution Guide Step 2 2. Once you have received our response to your initial Provider Contact Center inquiry and you disagree with the determination, you may escalate your concern by submitting a secure email to humanaproviderservices@humana.com . Be sure to include : • a. The reference number(s) associated with previous attempt(s) to resolve the inquiry (referenced in 1a above) • b. Health care provider name and tax ID number • c. Member name and identification number, including the relationship of the member to the patient • d. Date of service, claim number and name of the provider of the services • e. Charge amount, actual payment amount, expected payment amount and a description of the basis for the contestation • f. Contact information for our response 10
Claim Payment Inquiry Resolution Guide Step 3 3. Look for an “Acknowledgment of Submission” email with a tracking number within five business days of your submission. Please allow 30 to 45 days from the date of the acknowledgment notice for our response. • The specialist assigned your inquiry will provide an update every 14 days regarding the status of your submission until the submission is complete. 11
Claim Code Edits • Code editing is the process of evaluating information submitted on a claim. The information considered includes, but is not limited to: – Procedure codes, diagnosis codes, revenue codes, billing units, and modifiers – Attributes of the member, such as age or gender 12
Claim Code Edits, continued • Humana applies code editing to: • Validate the accuracy and integrity of codes submitted for payment consideration • Ensure consistent and appropriate processing of member claims, based on the services billed • Facilitate accurate reimbursement for providers • Administer Humana’s policies and industry standard coding guidelines • Maintain compliance with coding, clinical and regulatory guidelines 13
Appeals and Reconsideration Participating providers can request • Appeals on behalf of the member • a “reconsideration” which is must be submitted to Humana handled through our within 60 days from the date of the Correspondence Department denial. Provider Reconsiderations should • be sent to: • Appeals should be sent to: Humana Humana Provider Reconsiderations Provider Appeals PO Box 14601 P.O. Box 14165 Lexington, KY 40512-4601 Lexington, KY 40512-4165 14
Provider Payment Integrity (Financial Recovery) 15
Provider Payment Integrity – Types of Audits • Global Audits - Focuses on overpayment issues that are not provider specific (COB, Duplicates, Retro Contract Terms) • Contractual Audits – Focus is to ensure claims are paid in accordance with provider contract – queries target provisions within provider contracts (i.e., Stop Loss, Carve-Outs, etc.) • Clinical Audits - Use internal team & vendors with clinical expertise (physicians, nurses, coders, pharmacists, etc) to review medical records and identify potential overpayments due to incorrect coding and billing, services did not meet medical necessity criteria, etc. 16
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