1. Introduction for Health Care Providers and Administrators to Humana Medicare Advantage Plans
November 14,2014

2. About Humana
Humana is one of nation’s 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

3. Humana and Health Care Reform
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:

4. Medicare Coverage Options
One plan, one plan premium, one company
Medicare Advantage health plan only (MA only)
Includes all the benefits of
Original
Medicare
(Part A – Hospital)
(Part B – Medical)
Stand-alone Part D (outpatient pharmacy)
MAPD – MA health plan with Part D included

5. About Humana’s Medicare Plans

6. Humana Medicare Health Plans
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.

7. RightSource Rx

8. 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

9. How to Prescribe with RightSourceRx
To submit new RightSourceRx prescriptions
Transmit directly to RightSourceRx via electronic
prescribing capabilities
Call , or
Fax a physician prescription fax form to
(Fax forms are available online at RightSourceRx.com)

10. Additional Member Benefits

11. Additional Member Benefits
Vision
Dental
Complimentary Alternative Medicine (CAM) Network – network offering discounts at alternative health care providers
Hearing Aid benefits for SNP only

12. Interacting with Humana Via the Internet

13. Provider Website: Humana.com/providers
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:

14. Accessing the Provider Self-Service Center
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

15. Help with the Provider Self-Service Center
Help is available from
Provider’s own tech support
A Humana e-business consultant at
Training information is available from
An e-business consultant at
Humana’s provider website at

16. Claims and Related Issues

17. Submitting Claims Claims clearinghouses:
Availity
ZirMed
Athenahealth
Gateway EDI
McKesson
Capario
SSI Group
Details at: electronic_submission.asp

18. The Claim Management 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

19. Submitting Paper Claims
See the member’s ID card for correct claim or encounter mailing address
Find addresses at claims_encounter.asp

20. Claims Processing Edits
Edits support Humana's continuing efforts to process claims fairly, accurately and appropriately.
Edits relate to
The American Medical Association’s 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: processing_edits.asp

21. Claims Issues Check the status of a claim by:
Visiting the Provider Self-Service Center
Using Humana’s automated system ( ASSIST)
Speaking with a customer care specialist ( ASSIST)
The claims research team will review any claims that need further research and contact the appropriate health care provider

22. Financial Recovery
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
Disputing the letter in writing
Mailing a refund check

23. Financial Recovery Addresses
To send a refund:
Humana Health Care Plans
P.O. Box
Atlanta, GA
To dispute an overpayment letter:
Attn: Financial Recovery Correspondence
P.O. Box 14601
Lexington, KY

24. ERAs and EFTs 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 provider’s bank account

25. Getting Started with ERAs and EFTs
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
Phone number
Tax identification number
Details of two checks from Humana

26. ERA and EFT Capabilities
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

27. Referral, Preauthorization, and Utilization Management

28. Humana Gold Plus (HMO) PCP Referral Process for out of network providers
The PCP initiates a referral by submitting a request to Humana using any one of the following processes:
Humana.com/providers
[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

29. Preauthorization and Notification
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: pre_authorization.asp

30. Utilization Management Vendors
HealthHelp for radiation therapy
diagnostic imaging and
specific cardiac services
OrthoNet for pain management
and outpatient therapy

31. Radiology
Radiology services are administered by HealthHelp, a national recognized radiology benefit management organization
Preauthorizations and notifications are handled through HealthHelp’s RadConsult service

32. Radiology Exclusions and Pre Authorization
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/humana
By phone
Call the call center at
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

33. For More Information on Radiology
Education –on-Demand: provider_tools/education_on_demand.asp
RadConsult program support team
Available 8 a.m. to 8p.m. Eastern time, Monday through Friday; 10 a.m. to 5 p.m., Saturday

34. Pain Management
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

35. Pain Management Exclusions and Preauthorization
Request prior authorization by one of the methods below:
Online
Log into the Provider Self-Service Center or the secure provider area at
By phone
Call OrthoNet at
Representatives are available from 8:30 a.m. to 8:30 p.m. Eastern time, Monday through Friday.
By Fax
Fax OrthoNet at

36. Outpatient Therapy
OrthoNet also administers outpatient therapy services
Covered services include:
Physical therapy
Occupational therapy
Speech therapy

37. Contacting OrthoNet about Therapy Services
Fax preauthorization requests to OrthoNet at
Call for other inquiries

38. Clinical Management Programs

39. Episodic 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
Preventive health education
Disease management referral
Pharmacy/benefit maximization
Community resource coordination
Identification of special status members (e.g., institutional, end-stage renal disease and hospice)
Benefit education and guidance

40. HumanaCares – Complex Care Management
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

41. Humana Clinical Programs
Bariatric management program
Behavioral health
Medication therapy management (MTM)
Transplant management
HumanaFirst ® Nurse Advice Line

42. Utilization Management (UM) – Post-Acute Care
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

43. Connecting with Clinical Management
Physicians can refer members
Members can self-refer
The Clinical & Healthcare Resources Web page can be found at:

44. Helpful Phone Numbers
Medicare customer service: See back of member’s ID card
Authorization/IVR
Provider relations
Provider Payment Integrity
Medicare general case management
Concurrent review
Disease management program Information:
RightSourceRx pharmacy:
Availity customer service/tech support:
Financial Recovery

45. For follow-up questions