Humana Releases Latest Claims Payment Policy Updates

October 2019 ~

Humana has published its latest medical claims payment policy updates, including its reimbursement policy for ambulance transportation, requirements for billing and documentation of observation services, as well as a new policy for obstetric billing, including antepartum, delivery and postpartum care. A summary of these updates can be seen below.

Policy: Electronic Transactions NEW

This Medicare Advantage, commercial and Medicaid policy update establishes Humana’s policy on electronic transactions.

Update: Humana encourages electronic transactions for claim submission, reimbursement and explanation of remittance advice.

Policy: Obstetrics NEW

This commercial policy establishes how Humana plans reimburse charges for obstetric billing, including antepartum, delivery and postpartum care.

Update: Humana has updated the following obstetric billing procedures:

• Services Provided Before Initiation of Antepartum Record
• Global OB Packages
• Services Excluded from the Global OB Package
• When the Same Provider Renders Less than a Global OB Package
• Coding Summary
• Increased Procedural Services
• High-Risk Pregnancy and Pregnancy Complications
• Maternal-Fetal Medicine Specialists
• Gestation of Twins
• Fetal Nonstress Test
• Prolonged Physician Services
• Treatment of Conditions Unrelated to Pregnancy

Policy: Ambulance Transportation to a Prior-Authorized Facility NEW

This Medicare Advantage and commercial policy establishes Humana’s reimbursement policy for ambulance transportation to a prior-authorized facility

Update: Depending on plan type and other factors, coverage of services at a particular facility may or may not require prior authorization. Regardless of whether prior authorization is required for services to be performed at a particular facility when Humana authorized admission to the facility in advance, Humana also reimburses for mileage for the related ambulance transportation to that facility. Humana limits reimbursement of ambulance mileage to the amount appropriate for the medically necessary and reasonable level of transportation, that is, ground versus air. In this scenario, a provider should bill all of the coverable mileage with HCPCS code A0425, A0435 or A0436. However, Humana notes, if a provider bills mileage with HCPCS code A0888, Humana plans will not reimburse that charge but will deny it to provider liability.

If the facility did not obtain prior authorization from Humana for the related admission, a provider should bill mileage for transportation beyond the closest facility with HCPCS code A0888. Humana plans will not reimburse that charge but will deny it to provider liability.

Policy: Missed Appointments NEW

This policy update outlines Humana’s expectations for a provider charging a patient for a missed appointment.

Update:

Medicare Advantage Payment Policy

In addition to the policy, claims payments are subject to other plan requirements for the processing and payment of claims, including, but not limited to, requirements of medical necessity and reasonableness and applicable referral or authorization requirements.

Humana Medicare Advantage (MA) plans recognize that a provider can charge a patient for a missed appointment, as long as the provider applies their policy according to the standards outlined in Chapter 1, Section 30.3.13 of the Medicare Claims Processing Manual. Therefore, a provider must apply any policy regarding a missed appointment equally to all patients, whether they are enrolled in the Medicare Program or not. A missed appointment fee must be the same for Medicare beneficiaries and patients who are not Medicare beneficiaries. The fee is not a charge for a health care service but compensates the provider for a missed business opportunity.

A hospital may charge a patient for a missed appointment in the hospital’s outpatient department only if the patient is not receiving inpatient services at the time of the missed appointment. However, if a registered hospital inpatient misses an appointment in the hospital’s outpatient department, the hospital would violate 42 CFR 489.22 if it were to charge the patient a missed appointment fee.

Consistent with Original Medicare, Humana MA plans do not reimburse for a missed appointment charge imposed by a provider. A missed appointment fee should not be billed to Humana. If a provider submits a charge to Humana for a missed appointment fee, Humana will deny the charge, indicating the service is not covered under the patient’s MA plan.

Commercial Payment Policy

In addition to the policy, claims payments are subject to other plan requirements for the processing and payment of claims, including, but not limited to, requirements of medical necessity and reasonableness and applicable referral or authorization requirements.

Humana permits a provider to charge a commercial plan enrollee for a missed appointment unless prohibited by state law, the member’s plan’s certificate, Humana’s provider manual or other applicable standard.

Humana commercial plans do not reimburse for a missed appointment charge imposed by a provider. A missed appointment fee should not be billed to Humana. If a provider submits a charge to Humana for a missed appointment fee, Humana will deny the charge, indicating the service is not covered under the patient’s commercial plan.

Source(s): Humana;