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Important Reminders:
Humana Policies and Processes
Humana has a wide range of policies and procedures to serve
its members and support its network physicians. Following is a review of
some of the key policies.
Utilization management (UM)
The utilization management program helps guide Humana members to a more
satisfying experience. It is important that physicians, other health care
providers and Humana members know the following about the program:
- Humana uses nationally
recognized guidelines for all utilization review and coverage
determinations.
- Humana does not reward
health care providers for denying service or care.
- Los incentivos financieros nunca son parte de una decisión de la UM.
- Physicians can obtain a
copy of specific UM criteria from their local market office upon
request.
Clinical practice guidelines
Clinical practice guidelines are available on the provider area of Humana's
Web site at www.humana.com.
Click on "Providers," and then click on "Tools &
Resources." Select "Provider Tools," then click on
"Clinical & Healthcare Resources." Then select "Clinical
Practice Guidelines," and choose from the list of available clinical
practice guidelines.
The specific links take you from Humana's Web site to the Web site
of the organization that issued the guidelines. For example, the childhood
immunizations link takes you to the Web site for the American Academy
of Pediatrics. Paper copies of the guidelines may also be requested from
your local market office.
Disease management (DM)
Humana offers several disease-specific programs for complex, chronic
conditions. These programs are designed to complement the physician's
treatment plan and empower the member through education and support.
Information about available DM programs and procedures for accessing
services are available on Humana's Web site at www.humana.com. Click on
"Providers" and then select "Health & Wellness" to
see a list of links to specific DM programs.
Adverse determinations/denial decision
In the event of an adverse determination or denial, the member's attending
physician or primary care physician (PCP) is entitled to discuss the
decision with a Humana regional medical director or pharmacist reviewer. A
peer-to-peer conversation may be scheduled by calling the local market
office or by calling the number in the denial notification letter. In cases
when another opinion may be needed, an External Review Organization (ERO)
board-certified specialist may be consulted.
Urgent/emergent services
Covered members have access to urgent/emergent services for screening and stabilization
24 hours a day, seven days a week, in or out of the service area as long as
the member perceives an emergency situation exists according to the
"prudent layperson" standard. This means that a person with
average knowledge of health services and medicine, acting reasonably, would
have believed an emergency existed. No referral or authorization is
required for emergency visits.
Quality Improvement (QI) program
Humana has a comprehensive quality improvement program that encompasses
clinical care, preventive care and administrative functions of the health
plan. Physicians may obtain a written QI program description by contacting
Humana customer service at 1-800-4-HUMANA (1-800-448-6262). For a progress
report of how goals are being met in individual markets, mail a request to
the following address:
Lynn Lee c/o Humana
Progress Report
321 West Main, 20 WFP
Louisville,
KY 40202
Members' rights and responsibilities
All commercial and Medicare Humana members have certain rights and
responsibilities when being treated by Humana-contracted physicians. These
rights are outlined in Humana's Rights and Responsibilities statement.
Physicians can find a copy of the statement in their provider manual and in
informational packets for new practitioners. Humana asks participating
physicians to display a copy of the Rights and Responsibilities statement
in their offices. Provider manuals can also be downloaded from www.humana.com; from the provider home page, click on "Provider
Manuals" listed under "Quick Links" on the right.
Medical record audits
Humana conducts medical record audits in randomly selected physician
offices to monitor and improve record-keeping practices. The minimum
passing score is 85 percent with a goal of 90 percent. Guidelines for
medical records documentation adopted from the National Committee for
Quality Assurance (NCQA) and Medicaid Managed Care Quality Assurance Reform
Initiative (QARI) are available on the National Health Service Corps Web
site at: http://nhsc.bhpr.hrsa.gov/resources/SRM-toc.asp
(Chapter 13) or a copy may be obtained from the local Humana market office.
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