Terms and Conditions

You will not have a contract with Humana Private Fee-for-Service (PFFS), but you are a participating provider if:

• You have knowledge that your patient is enrolled as a member in a Humana PFFS Plan. (Humana PFFS Plans will provide Members with an identification or enrollment card);
• You have a reasonable opportunity to obtain the Terms and Conditions for participation in Humana PFFS Plans that are set out herein or available on Humana.com;
• You provide services to a Humana PFFS Member.

In addition, you:

• Must be licensed or certified by the state and be acting within the scope of that license or certification, and not be sanctioned or have opted out of Medicare.
• Must comply with all Medicare and other federal health care program laws, regulations and program instructions that apply to the services furnished to Members
• Agree not to balance bill Members, and collect from Members only their Humana MA PFFS Plan cost-sharing amounts, if you accept assignment of the Medicare payment from the Member
• Agree to collect from Members only the Humana MA PFFS Plan cost-sharing amounts and the Medicare limiting charge if you do not accept assignment of the Medicare payment from the Member

Agree that in no event, including, but not limited to: nonpayment by Humana PFFS, Humana PFFS insolvency or breach of this Agreement, shall you or your assignees and/or subcontractors bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members of Humana PFFS or persons other than Humana PFFS acting on their behalf, for covered services provided to the Member by you. This provision shall not prohibit collection of payments for any noncovered services or Member cost-share amounts set forth above. You further agree that: (i) this provision supersedes any oral or written contrary agreement now existing, or hereafter entered into between you and a Member or persons acting on his/her behalf and (ii) this provision shall apply to all of your employees, agents, trustees, assignees and subcontractors, and you shall obtain from such persons specific agreement to this provision.

Agree to cooperate with Humana’s Medicare Risk Adjustment program, including, but not limited to, medical record reviews.

Agree to comply with all Humana PFFS appeal and grievance procedures, including hospitals, skilled nursing facilities, home health agencies or certified outpatient rehabilitation facilities providing appropriate written notices to Members in advance of service ending. Copies of those procedures are available upon request from the provider relations department, by calling 866-291-9714.

Agree that if you do not agree to accept the Terms and Conditions stated herein, you may not provide services to a Humana PFFS Member.

Providers who agree to the Humana PFFS Terms and Conditions are reimbursed for Medicare-covered services at current Medicare reimbursement rates, less the Member's cost-share amount. 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.

Humana will comply with all CMS rules and regulations regarding prompt payment of claims for claims that have been submitted by Providers for services and supplies rendered to Medicare Advantage members.

Federal health care providers are not eligible for payment for services to Humana PFFS Members, except for emergency services.