Humana’s Most Common Denial Reasons

What You Can Do

Listed below are Humana’s top reasons for reimbursement denials, according to information provided to the OSMA by Humana. They are listed in descending order, beginning with the most frequent reason for denial. The OSMA is seeking this type of information from all major Ohio insurers in order to help practices become more cognizant of denial reasons. Below each denial is practical information regarding the steps you can take to avoid these denials.

Procedure is not allowed separately as it is part of a global code – Global CPT codes are used when related and concurrent procedures are bundled together into a single episode and billed and paid together. If you submit a claim for a procedure or office exam on a patient that recently underwent a global episode (for example a surgery global code may include surgical procedure, suturing, bandaging of a wound and follow-up office exam), then that claim will be denied if the individual code is included in the global bundle.

• What to do: Humana’s claims edit package is based on the Correct Coding Initiative (CCI) edits. Certain changes are made as recommended by Humana’s Clinical Edit Review Team. Practices should look at availity.com and locate “provider tools” under the providers section for more information about specific edits. Becoming knowledgeable about global bundling can save your practice the time and money of claim submissions and denial management.

Duplicate billing – Often times, when some practices are not certain if Humana has received their claim, they resubmit it. Other practices will set their claims submission systems to automatically submit another claim if the first claim submission is not paid or denied within a specific time period. Once the first claim gets adjudicated all subsequent duplicate claims will be denied.

• What to do: Duplicate claims add costs to your practice because you may have submission fees from your clearinghouse, and it takes staff time to deal with the denials. One way to address the question of whether Humana has received the claim is to verify its status on availity.com. If you have your practice management system set to automatically generate another claim, then Humana recommends that you set it for 30-45 days out so that Humana has time to adjudicate the original claim.

Charges are after coverage has ended – The services were provided on a date after the patient’s coverage has ended.

• What to do: To avoid billing Humana for a patient that no longer has coverage check the patient’s eligibility using availity.com or call 1-800-4HUMANA. If the patient is not eligible, ask the patient if he or she has another insurance card or other coverage. Check eligibility as close to the date of service as possible, because people tend to use their insurance more if they know it is going to end.

Service not covered by plan – The patient is a current member of a Humana plan, but the plan does not cover the service that you billed.

• What to do: This is similar to eligibility in that it is important that you not only check eligibility, but also that you check for particular service coverage. The fastest way to check coverage is to log on to availity.com, or call (800) 4HUMANA.