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

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Presentation on theme: "Introduction for Health Care Providers and Administrators to Humana Medicare Advantage Plans November 14,2014."— Presentation transcript:

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


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