Humana Claim Payment Policy Updates
March 2019 ~
Humana has released four updated medical claims payment policies, which includes changes to its screening colonoscopy, Medicare opt-out, Modifier 78, and Modifier EY policies. These updates can be seen below.
Screening Colonoscopy Medicare Advantage and Commercial Payment Policy
Humana plans may cover screening colonoscopies and screening colonoscopies that result in a diagnostic or therapeutic procedure. Members and providers should contact Humana for specific plan information.
- When billing screening services, health care providers must report an International Classification of Diseases (ICD) diagnosis code that accurately describes the screening.
- If the service begins as a screening procedure but results in a diagnostic or therapeutic procedure at the same operative session, health care providers should report an appropriate screening ICD diagnosis code as the primary diagnosis and the diagnostic or abnormal finding ICD diagnosis code as the secondary or subsequent diagnosis.
- When a screening results in a diagnostic or therapeutic procedure, as noted above, Humana will still consider the procedure as a screening if the following conditions are met:
– The member has a screening colonoscopy benefit; and
– The claim contains both a screening and diagnostic diagnosis code and can be supported by medical records; and
– For commercial plans, another screening colonoscopy has not been allowed for a date of service during the previous 12 months; or, for Medicare Advantage plans, the charge is not for a service performed more frequently than allowed, with respect to the previously allowed colorectal cancer screening, by Original Medicare guidelines.
Health care providers should report modifiers PT and 33 when appropriate.
Medicare Opt-Out Medicare Advantage Payment Policy
Effect of Private Contract
In no case do Humana MA plans reimburse a charge for services rendered pursuant to a valid private contract between an opt-out provider and an MA member.
Humana may recoup any claim payment made for services furnished by an opt-out provider if it is determined a private contract between the opt-out provider and the MA member was in effect at the time the services were furnished.
Non-Emergency and Non-Urgent Care Services
Humana MA plans deny a charge submitted by an opt-out provider for services that are not emergency or urgent care services.
Emergency and Urgent Care Services
Humana MA plans may reimburse a charge for services rendered and submitted by a provider who has opted out of the Medicare Program only for emergency or urgent care services, and only if the provider does not have a private contract with the MA member.
An opt-out provider must report modifier GJ when submitting a charge for emergency and urgent care services. Medical records must be available to substantiate that the services were truly for emergency or urgent care services. Humana MA plans deny a charge submitted by an opt-out provider without modifier GJ.
When an opt-out provider renders emergency or urgent global surgical services, the provider must submit modifier 54 to indicate only the intraoperative portion of the service was furnished, along with modifier GJ. When modifier 54 is billed, Humana MA plans reimburse only the intraoperative portion of the base maximum amount payable under the member’s plan.
Member Request for Reimbursement
A Humana MA member may not request payment from a Humana MA plan for services furnished by an opt-out provider. Humana MA plans are funded by the Medicare Program of which the provider has chosen to opt-out for the two-year period.
Exception: A member may submit requests for reimbursement, and a Humana MA plan may reimburse them, in the following situations if the service was not rendered pursuant to a private contract between the opt-out provider and the MA member:
- Humana MA plans may reimburse charges on the first claim received from an MA member for services furnished by an opt-out provider. If the Humana MA plan reimburses for any charge received on a member-submitted claim, Humana will also send a member notification letter.
- Humana MA plans may reimburse charges for services rendered 15 or fewer days after the postmark of the member notification letter. Humana MA plans do not reimburse charges for services rendered more than 15 days after the postmark of the member notification letter.
Opt-Out Member Notification Letter: The member notification letter explains that the provider has opted out of the Medicare Program, and that the member can choose to:
- Privately contract with the opt-out provider, agreeing to accept personal financial responsibility for all services; or
- Seek services from a provider who has not opted out of the Medicare Program.
Limitations on Allowed Amounts
When reimbursing a service rendered by a provider who has chosen to opt out of the Medicare Program, Humana MA plans apply reimbursement limitations, such as limiting charge amounts, when appropriate.
Modifier 78 Medicare Advantage and Commercial Payment Policy
This policy applies only to charges for practitioner services for procedure codes identified, in the Medicare Physician Fee Schedule (MPFS) Relative Value file, as having global surgery periods.
Humana plans consider a return trip to the operating or procedure room, as indicated by the use of modifier 78, as surgical only and allow the appropriate rate for the service, which is the practitioner’s contracted rate or base maximum amount payable under the member’s plan, multiplied by the MPFS intraoperative percentage.
For a charge for an unlisted code submitted with modifier 78, Humana plans allow 50 percent of the intraoperative amount of the original surgical procedure that resulted in the return to the operating or procedure room.
Multiple surgery and bilateral rules do not apply on return trips to the operating or procedure room.
Reimbursement for modifier 78 charges for assistant at surgery services is not subject to multiplication by the intraoperative percentage.
It is inappropriate to bill modifiers 76, 77 or 79 with modifier 78; therefore, Humana plans deny a charge submitted with modifier 78 and any of those modifiers.
Modifier EY Medicare Advantage and Commercial Payment Policy
The following policy applies to professional services only.
Humana plans only allow services that have been ordered by a physician or other licensed health care practitioner. Therefore, Humana plans do not reimburse for a charge reported with modifier EY.
For more information and full details on these updates, refer to Humana claims payment policies.