Humana Issues for IIRC Roundtable – March 1, 2012

1. Tina Spannknebel, Hospital Internal Medicine Associates

a. Why do we have to pay to participate in the Medicare HMO Plan? It seems it should be handled the same as any other Humana plan.
Response
There is no payment required by Humana to participate with Humana MA HMO.

b. How do we update our online access on Humana’s website and add users?
Response
You may contact Tammy Ubach at for assistance.

2. Angela Hibbs, Chest Medicine Associates


A lot of times when I have to call customer service it will ask for the patients ID # so I get the correct department. Once the number is entered I get disconnected or I still don’t get the right department and have to be transferred and repeat everything over again such as patient ID, tax ID, patient name, DOB and practice name. I feel this information should be transferred with the call. I dread any time I have to call Humana for anything.
Response
Recently there were issues with our IVR system/phone lines due to system outages in other areas – availity.com and humana.com functionalities. Those have been corrected and we are no longer reporting any issues with IVR/phone lines.

3. Deb Lush, Specialty Orthopaedics PSC


We need a provider representative to help resolve issues that a customer service rep can’t seem to do. They lack training and read what is on the computer screen. Claims are denied by Orthonet and customer service refuses to speak to us since it was denied by Orthonet. When calling Orthonet they can not find the claim. The two entities do not work together.

Another issue is that Customer service requests that when we call on a claim to have the allowed amount available for them.
Response
Will need examples in order to have claim issue addressed and determine where breakdown in process occurs. Deb will provide claim examples which will be forwarded for review and response.

4. Michelle Bowling, Chmiel, Murphy & Secor


Humana requesting inordinate amount of medical records. Claims examples sent to Catherine.
Response: Humana requests medical records for many different reasons. The specific examples would need to be reviewed to respond to this.
Response
Examples received 2-22-12; Humana is reviewing the issue and will respond.

5. Theresa McCoy, Kentuckiana Allergy PSC


All of our allergy injection cpt codes of 95115 and 95117 are now being denied with adjustment code of PI-11 that states that the diagnosis is not consistent with the procedure codes. All of the 100’s of denials being received at this time have the correct diagnosis attached and Humana team leader states they just received notification that all allergy injections from all providers elsewhere are being denied with a glitch in Humana’s area. No fix date provided and how do we assure all of those 100’s plus claims will be corrected and when. Patients are calling upset that their claims are being denied with pointing blame on the practice for incorrectly submitting these claims. We should not have to resubmit all of those claims again and Humana should run a report that shows all denials codes of PI-11 and reprocess immediately as well as notify the patients of this Humana glitch.
Response:
A system update was made which inadvertently & inappropriately denied these services. Humana has implemented a process by which these claims will be manually adjudicated to keep them from denying. Once Humana is confident the manual process works we will run report(s) to process the claims that have already denied. The permanent fix will be made to the system in April to eliminate the manual process.

Please add for discussion for event today with Humana. On hold for 25 minutes until representative assisted us. Sent medical records in for patient per Humana request in October and never received payment or response. The representative today states it was delivered in October but never attended to as it is the busiest month of the year and representative said he does not really know what happened other than it got routed and unsure where to send it. He said it was pushed aside and never attended to again until our call today. REFERENCE NUMBER: 61194333335. Claim number was put on each page including fax page per Humana request at that time.

Another call today, on hold for 30 minutes, medical records sent in November 1, 2012 but Humana has never found it per representative. Representative state they are having problems retrieving medical records and ongoing issues per representative with medical records. REFERENCE: 064347285614.
Response:
We brought these shortcomings to CSR management for retraining/re-education of the CSRs. There may be system limitations at times that prevent CSRs from viewing documents they may normally have access to view. The claim has been reviewed and additional processing has been completed for Ref # 064347285614. The claim has been reviewed and additional processing has been completed for Ref # 61194333335.

Further Update on Fri 4-13-12 3:54pm email:

Claims were submitted for reprocessing this week after several factors were validated to ensure all appropriate claims were captured. Expected turnaround time for reprocessing to be complete is 45-60 days; there are ~9,000 claims impacted.

6. Diane Myers, East Louisville Pediatrics


We are still having problems with the allergy shots (codes 95115 and 95117). They are being denied for either “professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections is not expected for reimbursement with the diagnosis code(s) billed…or for Medical necessity. These codes are not always denied, so there is no rhyme or reason as to why sometimes they are. It is causing a LOT of additional administrative time. I will bring samples to the meeting.

Response:
The BC/BS Ford plan does not cover allergy injections. The Humana plan(s) offered to Ford does cover allergy injections.

A system update was made which inadvertently & inappropriately denied these services. Humana has implemented a process by which these claims will be manually adjudicated to keep them from denying. Once Humana is confident the manual process works we will run report(s) to process the claims that have already denied. The permanent fix will be made to the system in April to eliminate the manual process.

Claim #s for denial code OJ1

628463006

628463007

637941820

651199937

635791619

624192043

636761474

625045315

639230141

684149934

7. Charlotte Obst, TenderCare Pediatrics

a. Humana not paying 69210 with modifier. Denying as not separately reimbursable.
Response:
There is a joint editing project between the Code Edit area and Special Investigations for review of all code combinations with modifiers 59 and 25; this review was implemented in 2011. Traditionally these two modifiers have been used to break bundling edits and were at risk for inappropriate usage by providers. This review ensures that the modifiers are being used appropriately, and are supported by diagnosis and/or documentation.

This editing is specific to AMA guidelines and applies to all lines of business. The only claims for which these edits should not be applying are Medicare Supplemental and Commercial secondary claims. There is a blurb in every provider notification that we post about correct coding and modifier usage. They are on line for all providers to access, both par and nonpar.

Modifier 25 is used to communicate that an E&M service is “separately identifiable” from other services on the same Date of Service. There is an inherent E&M component for every procedure, which is why E&Ms are typically not appropriate (incidental) for billing/separate reimbursement on the same DOS. Historically this modifier may have automatically allowed an override of the edits that would deny the E&M code when billed with other procedures on the same DOS.

Modifier 59 indicates a procedure is “distinct procedural service” from other procedures on the same Date of Service that normally would be considered a bundled (either incidental or mutually exclusive) service. Not all procedures are appropriate for a 59 override of the bundling edits. Documentation must support why a service typically considered bundled should be considered as distinct. Such reasons could be that the procedure was performed at a separate session, separate site or organ system, separate incision, or separate injury, etc.

We have several different edits that now help ensure the use of -25 and/or -59 are being applied appropriately by the providers. Some of our automated edits apply when only a single diagnosis has been submitted on the claim form. If only one diagnosis is submitted, then the provider is telling us both services billed are being rendered for the same condition, making it unlikely that the E&M is “separately identifiable” or that the procedure is “distinct” from another procedure rendered on the same Date of Service.

If the claim passes through our automated edits we also have a manual clinical review which is performed on all claim lines with modifiers 25 and 59. The information, especially the diagnoses, on the claim as well as historical claims by that same provider for that member are reviewed to confirm that the use of 25 or 59 is supported. For example, if there are multiple diagnoses but they all describe the same condition or if the provider’s billing indicates the current claim’s services were likely part of a predetermined treatment plan, then there is not enough information to support use of the modifier and the claim line will be denied. These manual edits are identified with EX 7MX and 15F. If these edits are applied, they may only be adjusted after a review of the medical records. If the provider submits records, they will be forwarded for clinical review to confirm service is separately identifiable and/or distinct.

Also not paying for wart removal billed with a sick or well visit. This just started end of January, 2012. On both issues, Humana is not even applying this to the deductible so that the patient would be responsible.
Response:
The example provided was: 17000-57 and 99213-25 when billed together are bundled and not separately reimbursable.

Modifier 25 is used to communicate that an E&M service is “separately identifiable” from other services on the same Date of Service. There is an inherent E&M component for every procedure, which is why E&Ms are typically not appropriate (incidental) for billing/separate reimbursement on the same DOS. Historically this modifier may have automatically allowed an override of the edits that would deny the E&M code when billed with other procedures on the same DOS.

Specific to modifier 57, it would not be appropriate to append to CPT 17000. Modifier 57 only applies to identify decisions for a major surgery and would be appended to the E&M. It states that the E&M is when the decision for a major surgery was made and therefore the E&M is separate from the major surgical procedure’s global period. In the code pair noted above: 1. 57 was appended to the procedure not to the E&M; 2. CPT 17000 is not a major surgery as it does not have a 90 day global period


b. Denials for the 90461 and 90460. I thought that Humana had the problem fixed but we have gotten one from 01/24/12 and 2/7/12.
Response:
Denial code 6Q has been corrected. System has been corrected to no longer inappropriately deny these codes due to the total # of units billed per 90460 line and per 90461 line; i.e. 90460 3 units, 90461 2 units.

Jan 2011 – July 2011 maximum # of reimbursable units is 5 for both 90460 & 90461. July 2011 – today maximum # of reimbursable units is 9 for 90460 & 7 for 90461.

Denial codes 66 or 88 may be seen today because the codes may be billed on separate lines with 1 unit per line vs. one line with the total # of units. 90460 & 90461 should each be billed on 1 line per code with the total # of units billed on the same line; i.e. 90460 5 units, 90461 3 units.

Claim #s

201112296632420 (from Lou Pediatric Specialists)

201112296018283 (from Lou Pediatric Specialists)

These claims include well child exam and immunization codes and are submitted on at least 2 claims due to the # of line items. If 90460/61 claim is processed first it denies as ‘primary procedure code hasn’t been processed, received or allowed.’ Humana requires medical records to be sent in for review before reprocessing.

Claims need to be submitted in HIPAA 5010 format vs. CMS format.


8. Advanced ENT & Allergy
Julie Breedlove,


Procedure code 31295 – Balloon Sinuplasty. Procedure has been approved by AMA and is a Status A with Medicare. There is RVU data for both office setting and facility. What could we provide to Humana to substantiate this procedure as approved form of treatment?
Response:
Policy provided


Issues Brought Forward During Roundtable:

9. Deb, Specialty Orthopaedics - When speaking with Customer Service and asking to speak with a supervisor it is refused.

Response: Catherine noted recent re-education has been done and if this is still occurring practices should contact her directly.

10. Terri, Endocrine & Diabetes Assoc - Is there a fax number to send documentation in response to request for records?

Response:
Humana does not have one fax number to which providers can send medical records, Humana does have the ability to accept medical records 2 ways in response to requests. 1. By mail – providers can mail medical records to the address printed on the EOB or letter. 2. Electronically – providers can submit medical records through humana.com or availity.com (instructions attached). Humana has a Medical Records Database which is a central repository to hold all Medical Records that are requested. All areas within the organization query this database before requesting records to make sure they haven’t already been received. There may be times a letter or EOB clearly states that medical records need to be faxed to a certain number; that means the medical records are being requested by a specific team.