Wiki Humana Claims not paying at random

[scubachic2004@msn.com]

I have a patient we have seen many times by different providers at our office. humana has paid all through 2012 and then the visit for november 2012 they didn't pay. No explanation on the RA at all. So I called talked to 2 different people was put on hold and they basically told me what I already knew. They had no answer to give me. Can anyone help me understand why at random they decide not to pay and make it patient responsibility. there is no valid reason why they didn't pay. HELP!!
Thanks!

 

[cassyn86]

Is it a totally different service than what they have previously paid or are they all the same services? Maybe it could be that the patients plan only pays a maximum number of a certain service and the patient had met that maximum before the november service?

 

[Dani_k_83]

Did you ask to speak to a supervisor? Or that they send the claim back thru for reprocessing? If the denial is determined to be pt resp and not a cwo, I would enlist the patient. They might be able to get a more informative answer as to why the claim was denied. Also, if you don't already have a provider rep for Humana, seek one out. Usually the best place to start would be with your contracting rep. I know for us, we use our rep for anything and everything we can.

 

[airart]

Payments stopped suddenly

When calling customer service ask them to check in the system for the denial or pending code that they are showing. You could easily look that up and find out the reason. If the CSR responds with not seeing anything, have them either connect you with a claims processor or a claims processor supervisor. If they deter from that you can ask for their supervisor or have them send the claim back for review and a call to you for the reason why claim did not pay. Other possibilities I have seen when payments stop after months of no problems is the patient hasn't responded to the COB questionnaire. This survey has to be completed annually and if it isn't done then the carrier will hold all claims til the patient responds to the survey. The provider will get an EOB the first time that the claim is pending patient response. Once they receive the information from the patient then they will re-process the claim and release payment. Its a pain, but I usually see this most often in cases you are describing.

I noticed on their web that as of October 2012 last year, Humana has started implementing the CCI edit update to finish rolling out in April 2013, so I am thinking we will be seeing more issues in the next few months with their system and their people being able to see what the system is doing and why. Good Luck everybody! Pay extra close attention to those Humana EOBs.