November 14,2014 Introduction for Health Care Providers and
Administrators to Humana Medicare Advantage Plans
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Humana is one of nations largest publicly traded health
benefits companies with 11.2 million medical members 7.3 million
specialty-product members Offers a wide array of plans for employer
groups, government programs and individuals Offers a range of
specialty products, including dental and vision plans Operates more
than 300 medical centers Operates more than 240 worksite medical
facilities About Humana
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Humana works diligently and is dedicated to staying in step
with health care reform Humana follows guidance and mandates from
the Centers for Medicare & Medicaid Services (CMS) Providers
can go to the following website for updates on Health Care Reform:
www.HealthCare.govwww.HealthCare.gov Humana and Health Care
Reform
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One plan, one plan premium, one company Medicare Coverage
Options Includes all the benefits of Original Medicare (Part A
Hospital) (Part B Medical) Medicare Advantage health plan only (MA
only) Stand-alone Part D (outpatient pharmacy) MAPD MA health plan
with Part D included
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About Humanas Medicare Plans
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Humana Gold Plus Health Maintenance Organization (HMO) Medicare
supplement (Medigap) plans Humana Gold Choice
Private-Fee-for-Service (PFFS) HumanaChoicePPO Preferred Provider
Organization (PPO) Humana Gold Plus HMO Point-of-Service (HMO-POS)
Medicare Advantage Special Needs Plans (SNP) Please note: Plans
offered vary by area/region. Humana Medicare Health Plans
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RightSource Rx
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Prescription Home-Delivery Service RightSourceRx is safe,
accurate and convenient Developed for Humana members who: Are
concerned about their prescription drug costs Have physical
difficulty getting prescriptions filled Are interested in a new
pharmacy solution
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How to Prescribe with RightSourceRx To submit new RightSourceRx
prescriptions Transmit directly to RightSourceRx via electronic
prescribing capabilities Call 1-800-379-0092, or Fax a physician
prescription fax form to 1-800-379-7617 (Fax forms are available
online at RightSourceRx.com)
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Additional Member Benefits
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Vision Dental Complimentary Alternative Medicine (CAM) Network
network offering discounts at alternative health care providers
Hearing Aid benefits for SNP only Additional Member Benefits
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Interacting with Humana Via the Internet
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Public section Health and wellness information Clinical
practice guidelines Provider publications Provider network
directories (corrections to your demographic information can be
provided to us electronically) Secure section (Provider
Self-Service Center) Patient eligibility and benefits
Preauthorization requests Referral and claims submissions Referral
and claims status Fee schedules Delegation of work to a contracted
billing services More information Humana e-business consultant
at:1-877-260-7360 Provider Website: Humana.com/providers
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Providers should do the following: Go to Humana.com/providers
Select Register for Self-Service Choose Provider Select provider
type: Physician Group Affiliated Provider Third-Party Administrator
(TPA) or Billing Service Choose Register/Create a New Application
Complete and submit the application Accessing the Provider
Self-Service Center
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Help is available from Providers own tech support A Humana
e-business consultant at [email protected]@humana.com
1-877-260-7360 Training information is available from An e-business
consultant at [email protected]@humana.com Humanas
provider website at
http://www.humana.com/providers/explore/interactive.asp
http://www.humana.com/providers/explore/interactive.asp Help with
the Provider Self-Service Center
Health care providers can submit Humana claims at no cost
through the Humana Provider Self-Service Center at
Humana.com/providers In some cases you can have a claim adjudicated
while the member is still in your office. For more information,
providers can contact a Humana e- business consultant The Claim
Management Center
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See the members ID card for correct claim or encounter mailing
address Find addresses at www.humana.com/providers/tools/claims/
claims_encounter.aspwww.humana.com/providers/tools/claims/
claims_encounter.asp Submitting Paper Claims
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Edits support Humana's continuing efforts to process claims
fairly, accurately and appropriately. Edits relate to The American
Medical Associations Current Procedural Terminology (CPT) code set
The Healthcare Common Procedure Coding System (HCPCS) code set
International Classification of Diseases code set, 9th
Edition/Revision (ICD-9) Details can be found at:
www.humana.com/providers/tools/claims/ processing_edits.asp
www.humana.com/providers/tools/claims/ processing_edits.asp Claims
Processing Edits
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Check the status of a claim by: Visiting the Provider
Self-Service Center Using Humanas automated system (1-866-4-ASSIST)
Speaking with a customer care specialist (1-866-4-ASSIST) The
claims research team will review any claims that need further
research and contact the appropriate health care provider Claims
Issues
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The Provider Payment Integrity Department handles overpayments
System-generated letters notify providers of overpayments Providers
have 45 days to respond. Options include: Calling the PPI
department at 1-800-438-7885 Disputing the letter in writing
Mailing a refund check Financial Recovery
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To send a refund: Humana Health Care Plans P.O. Box 931655
Atlanta, GA 31193-1655 To dispute an overpayment letter: Humana
Health Care Plans Attn: Financial Recovery Correspondence P.O. Box
14601 Lexington, KY 40512-4601 Financial Recovery Addresses
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Electronic remittance advices (ERAs) Remittance advices post
automatically, reducing administrative time and improving posting
accuracy Electronic fund transfers (EFTs) Payments are deposited
directly to health care providers bank account ERAs and EFTs
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To access the ERA/EFT Setup-Change Request Application,
providers should: Click the ERA/EFT Setup-Change Request link from
the secure section of the Provider Self-Service Center Choose Tools
and Resources from the public section of the provider website and
then click on Electronic Remittance Providers should enter the
required information: Name Email Phone number Tax identification
number Details of two checks from Humana Getting Started with ERAs
and EFTs
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Add ERAs and EFTs separately Add ERAs and EFTs together Change
file delivery method Change bank information Check the status of
transactions Cancel ERAs or EFTs that have been enabled ERA and EFT
Capabilities
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Referral, Preauthorization, and Utilization Management
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The PCP initiates a referral by submitting a request to Humana
using any one of the following processes: Humana.com/providers
1-800-523-0023 [Interactive Voice Response (IVR)] The PCP receives
a referral number from Humana if the request is: Complete and the
service is covered The service is medically necessary Please Note:
The referral status can be verified by accessing the sources listed
above Humana Gold Plus (HMO) PCP Referral Process for out of
network providers
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Preauthorization and notification allows Humana to Provide
members information on benefits Refer members to appropriate
clinical programs Humana requests preauthorization or notification
for several services and medications See the Quick Refer View
details at: www.humana.com/providers/tools/claims/
pre_authorization.asp www.humana.com/providers/tools/claims/
pre_authorization.asp Preauthorization and Notification
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HealthHelp for radiation therapy diagnostic imaging and
specific cardiac services OrthoNet for pain management and
outpatient therapy Utilization Management Vendors
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Radiology services are administered by HealthHelp, a national
recognized radiology benefit management organization
Preauthorizations and notifications are handled through HealthHelps
RadConsult service Radiology
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Requirements apply to CT scans, MRAs, MRIs, nuclear stress
tests, PET and SPECT scans and radiation therapy Requests are
handled through the RadConsult call center Online, visit
portal.healthhelp.com/humanaportal.healthhelp.com/humana By phone o
Call the call center at 1-866-825-1550 o Representatives are
available from 8 a.m. to 8 p.m. Eastern time, Monday through
Friday, and from 10 a.m. to 5 p.m. Eastern time, on Saturday
Radiology Exclusions and Pre Authorization
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Education on-Demand: www.humana.com/providers/tools/
provider_tools/education_on_demand.aspwww.humana.com/providers/tools/
provider_tools/education_on_demand.asp RadConsult program support
team 1-800-546-7092 Available 8 a.m. to 8p.m. Eastern time, Monday
through Friday; 10 a.m. to 5 p.m., Saturday Email:
[email protected] For More Information on Radiology
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Select pain management services are administered by OrthoNet, a
utilization management company Services for which preauthorization
is required include: Pain infusion pumps (back and neck pain only)
Spinal cord stimulator devices Spinal fusion Other decompression
surgeries Facet injection Epidural injections (outpatient only)
Kyphoplasty Vertebroplasty Pain Management
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Request prior authorization by one of the methods below: Online
Log into the Provider Self-Service Center or the secure provider
area at www.availity.com www.availity.com By phone Call OrthoNet at
1-888-605-5344 Representatives are available from 8:30 a.m. to 8:30
p.m. Eastern time, Monday through Friday. By Fax Fax OrthoNet at
1-888-605-5345 Pain Management Exclusions and Preauthorization
Fax preauthorization requests to OrthoNet at 1-800-863-4061
Call 1-800-862-4006 for other inquiries Contacting OrthoNet about
Therapy Services
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Clinical Management Programs
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Case Management Identifies high-risk members who may benefit
from case management (HRA or post- discharge assessment) Is based
on telephonic case management model Is episodic, typically within
30 to 90 days Objectives: Follow-up after inpatient admissions to
confirm medication and provider appointment compliance Make
post-discharge calls to help lower readmission rates, more
appropriate post-acute care rehab, and improved medication
compliance Focus on outpatient management and member guidance,
including o Preventive health education o Disease management
referral o Pharmacy/benefit maximization o Community resource
coordination o Identification of special status members (e.g.,
institutional, end-stage renal disease and hospice) o Benefit
education and guidance Episodic Case Management
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Provides chronically ill and frail members with holistic care
Provides a long-term relationship Provides telephonic and in-person
consultation by RNs and social workers to improve members
well-being Is a multidisciplinary approach Optimizes health
benefits, improves self-care management skills and prevents
unnecessary hospital stays and emergency room visits HumanaCares
Complex Care Management
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Bariatric management program Behavioral health Medication
therapy management (MTM) Transplant management HumanaFirst Nurse
Advice Line Humana Clinical Programs
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PPO Medicare Advantage plans require preauthorizations for
post- acute care for: Skilled nursing facilities, (SNF) Long-term
acute care hospitals (LTACH) Inpatient rehabilitation facilities
(IRF) Humana nurses review admission requests using InterQual
criteria Regional medical directors review 100% of LTACH and IRF
admissions Clinical associates review SNF cases for admission and
continued stay review UM helps facilitate the right care for right
member in the right setting UM helps prevent unnecessary long
lengths-of-stay Utilization Management (UM) Post-Acute Care
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Connecting with Clinical Management Physicians can refer
members Members can self-refer 1-800-322-2758 The Clinical &
Healthcare Resources Web page can be found at:
www.humana.com/providers/clinical/
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Medicare customer service:See back of members ID card
Authorization/IVR1-800-523-0023 Provider relations 1-800-626-2741
Provider Payment Integrity 1-800-438-7885 Medicare general case
management 1-800-322-2758 Concurrent review1-800-322-2758 Disease
management program Information:1-800-620-9529 RightSourceRx
pharmacy:1-800-379-0092 Availity customer service/tech
support:1-800-282-4548 Financial Recovery1-800-438-7885 Helpful
Phone Numbers