Humana Medicare Advantage Private-Fee-for-Service (PFFS) Plans Terms and Conditions of Payment

Table of Contents

1. Introduction

Humana Gold Choice^® PFFS and Humana Group Medicare PFFS are Medicare Advantage Private-Fee-for-Service (PFFS) plans offered by Humana. Humana Gold Choice PFFS and Humana Group Medicare PFFS plans allow members to use any provider, such as a physician, health professional, hospital, or other Medicare provider in the United States, that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B (also known as "Original Medicare") or eligible to be paid by Humana Gold Choice PFFS and Humana Group Medicare PFFS plans for benefits that are not covered under Original Medicare.

The law provides that if you have an opportunity to review these terms and conditions of payment and you treat a Humana Gold Choice PFFS or Humana Group Medicare PFFS member, you will be “deemed” to have a contract with us. Section 2 explains how the deeming process works. The rest of this document contains the contract that the law allows us to deem to hold between you, the provider, and Humana. Any provider in the United States that meets the deeming criteria in Section 2 becomes deemed to have a contract with Humana for the services furnished to the member when the deeming conditions are met. No prior authorization, prior notification, or referral is required as a condition of coverage when medically necessary, plan-covered services are furnished to a member. However, a member or provider may request an advance coverage determination before a service is provided in order to confirm that the service is medically necessary and will be covered by the plan. Note that the terms prior authorization, prior notification, and advance coverage determination have different meanings. Prior authorization and prior notification rules are described in Section 4, and advance coverage determination is described in Section 7.

2. When a provider is deemed to accept Humana Medicare Advantage PFFS plans Terms and Conditions of Payment

A provider is considered by law to be deemed to have a contract with Humana when all of the following three criteria are met:

1. The provider is aware, in advance of furnishing health care services, that the patient is a member of Humana Gold Choice PFFS or Humana Group Medicare PFFS. All of our members receive a member ID card that includes the Humana Gold Choice PFFS or Humana Group Medicare PFFS logo that clearly identifies them as PFFS members. The provider may further validate eligibility by calling our member/provider service number on the member's identification card or online at Humana.com.
2. The provider either has a copy of, or has reasonable access to, our terms and conditions of payment (this document). The terms and conditions are available on our Web site at Humana.com. The terms and conditions may also be obtained by calling our Humana Provider Relations Department at 1-866-291-9714.
3. The provider furnishes covered services to a Humana Gold Choice PFFS or Humana Group Medicare PFFS member.

If all of these conditions are met, the provider is deemed to have agreed to Humana Medicare Advantage PFFS terms and conditions of payment for that member specific to that visit. Note: You, the provider, can decide whether or not to accept Humana Medicare Advantage PFFS terms and conditions of payment each time you see a Humana Gold Choice PFFS or Humana Group Medicare PFFS member. A decision to treat one plan member does not obligate you to treat other Humana Gold Choice PFFS or Humana Group Medicare PFFS members, nor does it obligate you to accept the same member for treatment at a subsequent visit.

For example: If a Humana Gold Choice PFFS or Humana Group Medicare PFFS member shows you an enrollment card identifying him/her as a member of Humana Gold Choice PFFS or Humana Group Medicare PFFS and you provide services to that member, you will be considered a deemed provider. Therefore, it is your responsibility to obtain and review the terms and conditions of payment prior to providing services, except in the case of emergency services (see below).

If you DO NOT wish to accept Humana Medicare Advantage PFFS plans terms and conditions of payment, then you should not furnish services to a Humana Gold Choice PFFS or Humana Group Medicare PFFS member, except for emergency services. If you nonetheless do furnish nonemergency services, you will be subject to these terms and conditions whether you wish to agree to them or not. Providers furnishing emergency services will be treated as noncontract providers and paid at the payment amounts they would have received under Original Medicare.

3. Provider qualifications and requirements

In order to be paid by Humana for services provided to one of our members, you must:

• · Have a National Provider Identifier in order to submit electronic transactions to Humana, in accordance with HIPPA requirements.
• Submit your claims electronically whenever possible. For nonelectronic transactions, submit claims using the standard CMS-1500, CMS-1450, and/or UB-04, or their successors. Refer to Section 5, Filing a Claim for Payment for more details.
• Be licensed or certified by the state and furnish services to a Humana Gold Choice PFFS or Humana Group Medicare PFFS member within the scope of your licensure or certification.
• Provide only services that are covered by our plan and that are medically necessary by Medicare definitions.
• Meet applicable Medicare certification requirements (e.g., if you are an institutional provider such as a hospital or skilled nursing facility).
• Not have opted out of participation in the Medicare program under §1802(b) of the Social Security Act, unless providing emergency or urgently needed services.
• Not be on the HHS Office of Inspector General's excluded and sanctioned provider lists.
• Not be a federal health care provider, such as a Veterans Administration provider, except when providing emergency care.
• Comply with all applicable Medicare and other applicable federal health care program laws, regulations, and program instructions, including laws protecting patient privacy rights and HIPAA that apply to covered services furnished to members.
• Agree to cooperate with Humana to resolve any member grievance involving the provider within the time frame required under federal law.
• For providers that are hospitals, home health agencies, skilled nursing facilities, or comprehensive outpatient rehabilitation facilities, provide applicable beneficiary appeal notices (See Section 10 for specific requirements).
• Not charge the member in excess of cost sharing under any condition, including in the event of plan bankruptcy.
• Be a Medicare-certified provider for supplemental services.

4. Payment to providers

Plan Payment
Humana reimburses deemed providers at the amount they would have received as participating or nonparticipating physicians, as applicable, under Original Medicare for Medicare-covered services minus any member required cost sharing, for all medically necessary services covered by Medicare. In addition, settlement for certain payment methodologies is available upon request. When requesting settlement, provider represents and warrants that it qualifies under CMS laws, rules and regulations for the settlement requested. For further information, please contact your provider representative.

We will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, then we will pay interest on the claim according to Medicare guidelines. Section 5 has more information on prompt payment rules. Payment to providers for which Medicare does not have a publicly published rate will be based on the estimated Medicare amount. For more detailed information about our payment methodology for all provider types, please contact us at the member/provider service number listed on the back of the member's identification card.

Deemed providers furnishing such services must accept the fee schedule amount, minus applicable member cost sharing, as payment in full.

Member benefits and cost sharing
Payment of cost sharing amounts is the responsibility of the member. Providers should collect the applicable cost sharing from the member at the time of the service when possible. You can only collect from the member the appropriate Humana Gold Choice PFFS or Humana Group Medicare PFFS plan copayments or coinsurance amounts described in these terms and conditions. After collecting cost sharing from the member, the provider should bill Humana for covered services. Section 5 provides instructions on how to submit claims to us. If a member is a dual-eligible Medicare beneficiary (that is, the member is enrolled in our PFFS plan and a state Medicaid program) that the state holds harmless for Medicare cost sharing, then the provider cannot collect any cost sharing from the member at the time of service. Instead, the provider may only look to the state Medicaid agency to collect the Medicaid allowable cost sharing amount(s).

To view a complete list of covered services and member cost sharing amounts under Humana Gold Choice PFFS or Humana Group Medicare PFFS plans, go to Humana.com. You may call us at the member/provider service phone number listed on the back of the member's identification card to obtain more information about covered benefits, plan payment rates, and member cost sharing amounts under Humana Gold Choice PFFS or Humana Group Medicare PFFS plans. Be sure to have the member's ID number when you call.

Humana Gold Choice PFFS or Humana Group Medicare PFFS plans follow Medicare coverage decisions for Medicare-covered services. Services not covered by Medicare are not covered by Humana Gold Choice PFFS or Humana Group Medicare PFFS, unless specified by the plan. Information on obtaining an advance coverage determination can be found in Section 7. Humana Gold Choice PFFS or Humana Group Medicare PFFS plans do not require members or providers to obtain prior authorization, prior notification, or referrals from the plan as a condition of coverage. Under prior authorization, a plan requires beneficiaries or providers to seek authorization from the plan prior to obtaining services. There is no such requirement for Humana Gold Choice PFFS or Humana Group Medicare PFFS members. For information on Humana Gold Choice PFFS or Humana Group Medicare PFFS plans' prior notification policies, see section on "Prior Notification Rules" below.

Note: Medicare supplemental policies, commonly referred to as Medigap plans, cannot cover cost sharing amounts for Medicare Advantage plans, including PFFS plans. All cost sharing is the member's responsibility.

Prior Notification Rules
No prior authorization or referral is required as a condition of coverage when medically necessary, plan-covered services are furnished to members. However, to assist us in better managing care for our members, we request that you notify us prior to the member receiving any of the following services:

• Admission to a hospital, acute rehab facility, long-term acute care facility, skilled nursing facility, or mental health and partial hospital/residential treatment facility
• Observation stays
• Automatic Implantable Cardioverter Defibrillators (AICD)
• Lumbar and cervical fusion surgery
• Obesity surgeries
• Transplant services
• PET Scan/National Oncology PET Registry (NOPR)
• Outpatient therapy services, such as physical therapy, occupational therapy and speech therapy
• Maternity care

For questions about whether Humana Gold Choice PFFS or Humana Group Medicare PFFS will pay for services, you may request an advanced coverage determination (ACD) on behalf of the member prior to providing the service.

Humana Gold Choice PFFS or Humana Group Medicare PFFS plans do not require the member or provider to prior notify the plan as a condition for covering services. To provide prior notification, please call 1-800-523-0023 or go to Humana.com. To obtain more information about our prior notification rules, please visit Humana's Web site at Humana.com or call us at the member/provider service number listed on the back of our member's identification card.

Balance billing of members
A provider may collect only applicable plan cost sharing amounts from Humana Gold Choice PFFS or Humana Group Medicare PFFS members and may not otherwise charge or bill the members. Balance billing is prohibited by deemed providers who furnish plan-covered services to Humana Gold Choice PFFS or Humana Group Medicare PFFS members.

Hold harmless requirements
In no event, including, but not limited to, nonpayment by Humana, insolvency of Humana, and/or breach of these terms and conditions, shall a deemed provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a member or persons acting on their behalf for plan-covered services provided under these terms and conditions. This provision shall not prohibit collection of any applicable coinsurance, copayments, or deductibles billed in accordance with the terms of the member's benefit plan.

If any payment amount is mistakenly or erroneously collected from a member, you must make a refund of that amount to the member.

5. Filing a claim for payment

• You must submit a claim to Humana for an Original Medicare covered service within the same time frame you would have to submit under Original Medicare, which is within 15-27 months from the date of service. Failure to be timely with claim submissions may result in nonpayment. The criteria for Original Medicare submission of claims can be found in section 70 of Chapter 1 of the Medicare Claims Processing Manual located at http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
• Prompt Payment: Humana will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, Humana will pay interest on the claim according to Medicare guidelines. A clean claim includes the minimum information necessary to adjudicate a claim, not to exceed the information required by Original Medicare. Humana will process all nonclean claims and notify providers of the determination within 60 days of receiving such claims.
• Submit claims using the standard CMS-1500, CMS-1450 (UB-04) or the appropriate electronic filing format.
• · Use the same coding rules and billing guidelines as Original Medicare, including Medicare CPT codes, HCPCS codes and defined modifiers. Bill diagnosis codes to the highest level of specificity.
• Include the following on your claims:
  • National Provider Identifier
  • The member's ID number
  • Medicare ID
  • Date(s) of service
• · For providers that are paid based upon interim rates, include with your claim a copy of your current interim rate letter if the interim rate has changed since your previous claim submission.
• All Medicare secondary payer rules apply. These rules can be found in the Medicare Secondary Payer Manual located at http://www.cms.hhs.gov/Manuals/IOM/list.asp. Providers should identify primary coverage and provide information to Humana at the time of billing.
• Where to submit a claim:
  • For electronic claim submission, you can use your existing clearinghouse or Availity. Current Humana electronic submitters can use the same process they now use.
  • For paper claim submission, mail paper claims to the address that is listed on the back of the member ID card or:

    Humana
    P.O. Box 14601
    Lexington, KY 40512-4601
    

  • If you have problems submitting claims to us or have any billing questions, contact our technical billing resource at the member/provider service telephone number listed on the back of the member's ID card.

6. Maintaining medical records and allowing audits

Deemed providers shall maintain timely and accurate medical, financial and administrative records related to services they render to Humana Gold Choice PFFS or Humana Group Medicare PFFS members. Unless a longer time period is required by applicable statutes or regulations, the provider shall maintain such records for at least 10 years from the date of service. Deemed providers must agree to maintain medical records according to industry standards and to provide such records to Humana or a Humana designee upon request and within a reasonable time frame. Deemed providers must provide Humana, the Department of Health and Human Services, the Comptroller General, or their designees access to any books, contracts, medical records, patient care documentation, and other records maintained by the provider pertaining to services rendered to Medicare beneficiaries enrolled in a Medicare Advantage plan, consistent with federal and state privacy laws. Such records may be used for activities in the following situations: Centers for Medicare & Medicaid Services and Humana audits of risk adjustment data; CMS audits; fraud and abuse; compliance with federal regulations; Humana determinations of whether services are covered under the plan, are reasonable and medically necessary, whether the plan was billed correctly for the service; whether the service is coded properly; and in order to make advance coverage determinations. Humana will not use medical record reviews to create artificial barriers that would delay payments to providers. Both voluntary and mandatory provision of medical records must be consistent with HIPAA privacy law requirements.

7. Getting an advance coverage determination

Providers may choose to obtain a written advance coverage determination (ACD) (also known as an organization determination) from us before furnishing a service in order to confirm whether the service is medically necessary and will be covered by Humana Gold Choice PFFS or Humana Group Medicare PFFS plans. To obtain an advance coverage determination, all requests must be in writing and be mailed to:

Humana Advance Coverage Determination Correspondence
P.O. Box 14601
Lexington, KY 40512-4601

A written ACD request can also be faxed to 502-508-3551. Humana will make a decision and notify you within 14 days of receiving the request, with a possible 14-day extension either due to the member's request or Humana's justification that the delay is in the member's best interest. In cases where you believe that waiting for a decision under this time frame could place the member's life, health, or ability to regain maximum function in serious jeopardy, you can request an expedited determination. To obtain an expedited determination, call us at the member/provider service number listed on the back of the member's ID card or fax a request for ACD to 502-508-3551. For expedited determinations, we will notify you of our decision within 72 hours.

In the absence of an advance coverage determination, Humana can retroactively deny payment for a service furnished to a member if we determine that the service was not covered by our plan or was not medically necessary. However, providers have the right to dispute our decision by requesting a payment dispute or exercising member appeal rights.

8. Provider payment dispute resolution process

If you believe that the payment amount you received for a service is less than the amount indicated in our terms and conditions of payment, you have the right to dispute the payment amount by following our dispute resolution process.

To file a payment dispute with Humana, send a written dispute to:

Humana
P.O. Box 14601
Lexington, KY 40512-4601

Additionally, please provide appropriate documentation to support your payment dispute. This should include your name, address, the member's ID number and reason(s) for the payment dispute. Please send any supporting medical records, notes or other information that explains why the service should be paid. Claims must be disputed within 180 days from the date payment is initially received by the provider.

We will review your dispute and respond to you within 30 days. If we agree with your payment dispute, then we will pay you the additional amount with any interest that is due. We will inform you in writing if your payment dispute is denied.

After completing Humana's dispute resolution process, if you believe that we have reached an incorrect decision regarding your payment dispute, you may file a request for review of this determination with an independent entity contracted by CMS. To file a request for review of a payment dispute with the independent entity, you may contact the entity directly using any of the following methods:

Email.If the submission and associated documents do not contain any personally identifiable health information (PHI) (or any PHI has been redacted), the payment dispute decision request can be submitted to a dedicated email box at IREPFFS@FCSO.com.

Fax. (904) 361-0551

Mail. Providers can mail hard copy requests for payment dispute adjudication to the following address:

First Coast Service Options, Inc.
PFFS Payment Disputes
P.O. Box 44017
Jacksonville, FL 32231-4017

9. Member and provider appeals and grievances

Humana Gold Choice PFFS or Humana Group Medicare PFFS members have the right to file appeals and grievances when they have concerns or problems related to coverage or care. Members may appeal a decision made by Humana to deny coverage or payment for a service or benefit that they believe should be covered or paid. Members should file a grievance for all other types of complaints.

A provider may appeal decisions on behalf of a member as an appointed representative, or appeal on his or her own right using the member's appeal process by signing a waiver of liability (promising to hold the member harmless regardless of the outcome). There must be existing potential member liability (e.g., a claim, as opposed to an advance coverage determination, is denied as not medically necessary or a covered service) in order for a provider to appeal utilizing the member's appeal process. If you appeal on your own right, you agree to abide by the statutes, regulations, standards and guidelines applicable to the Medicare PFFS member appeals and grievances process.

The Humana Gold Choice PFFS or Humana Group Medicare PFFS member evidence of coverage (EOC) provides more detailed information about the member appeals and grievances process. The member EOC is posted on Humana.com. You can call our member/provider service number listed on the back of the Humana Gold Choice PFFS or Humana Group Medicare PFFS member's ID card for more information on our member appeals and grievances policies and procedures.

10. Providing members with notice of their appeal rights - Requirements for Hospitals, SNFs, CORFs and HHAs

Hospitals must notify Medicare beneficiaries who are hospital inpatients about their discharge appeal rights by complying with the requirements for providing the Important Message from Medicare (IM), including the time frames for delivery. For copies of the notice and additional information regarding this requirement, go to http://www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp.

Skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities must notify Medicare beneficiaries about their right to appeal a termination of services decision by complying with the requirements for providing Notice of Medicare Non-Coverage (NOMNC), including the time frames for delivery. For copies of the notice and the notice instructions, go to: http://www.cms.hhs.gov/MMCAG/Downloads/NOMNCForm.pdf and http://www.cms.hhs.gov/MMCAG/Downloads/NOMNCInstructions.pdf.

In addition, the provider should send a copy of any NOMNC issued to:

Humana Correspondence Office
P.O. Box 14611
Lexington, KY 40512-4611

Humana will provide members with a detailed explanation if a member notifies the Quality Improvement Organization (QIO) that the member wishes to appeal a decision regarding a hospital discharge or termination of home health agency, comprehensive outpatient rehabilitation facility or skilled nursing facility services within the time frames specified by law.

11. If you need additional information or have questions

If you have general questions about Humana Medicare Advantage PFFS plans terms and conditions of payment, contact us at:

Humana Provider Relations
333 Main Street
5th Floor
Green Bay, WI 54307

Phone: 1-866-291-9714
Fax: 1-800-626-1686
Hours of Operation: 8 a.m. to 7 p.m. CST, Monday through Friday

• If you have additional questions about submitting claims, call us at the member/provider service number on the back of the Humana Gold Choice PFFS or Humana Group Medicare PFFS member's ID card.
• If you have questions about plan payments, call us at the member/provider service number on the back of the Humana Gold Choice PFFS or Humana Group Medicare PFFS member's ID card.

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