Humana Provider Payment Integrity Medical Record Review Requirements

Humana, or its designee, has the right to conduct reviews of healthcare providers’ records related to services rendered to Humana-covered patients in certain circumstances. Humana requests access to medical records and billing documents periodically to conduct reviews. Upon request, the healthcare provider should be able to provide detailed itemizations of charges to support the supplies and services billed.



For an overview of Humana's review processes, please refer to the Humana Provider Payment Integrity Post-payment Review Policy and the Humana Provider Payment Integrity Prepayment Review Policy.

The healthcare provider should include all records and/or documentation that substantiate the services provided to the patient and all information necessary to allow accurate adjudication of the claim. A healthcare provider who does not submit or refuses to provide a medical record may receive a technical denial for medical record documentation not received. Please refer to the Humana Provider Payment Integrity Denial for Lack of Medical Records Policy and Humana Medical Record Types and Definitions for more information.

Types of records Humana or its designee may request include, but are not limited to, the following:

Activities of daily living (ADL) sheet, including flow sheets and/or logs

Admission assessments

Anesthesia records (including time of anesthesia administration)

Case management notes

Change of therapy (COT) assessment

Chat logs

Chemotherapy orders

Clinical trial information, including consents and treatment plans

Consultation notes

Diagnosis notes, including past medical history

Discharge/transfer summaries

Drawings and photos, when applicable

Emergency department reports

Evaluations: any evaluation related to the service provided

Face sheets

Face-to-face encounter documentation

For durable medical equipment/home infusion/home health: delivery receipts or proof of delivery for supplies or drugs

For inpatient rehabilitation: patient assessment instrument (PAI)

For skilled nursing facilities: minimum data set (MDS)

Hospice/end-of-life-care documentation

Implant detail: sticker sheet and copies of invoices for implants or high-cost drugs; implant logs with additional information on implants, screws and plates

Itemized bill

Laboratory and pathology reviews: Clinical reviews of pathology claims often require additional information to make determinations. Medical records from the ordering physician, as well as the requisition form and lab results, are necessary to complete a full and fair review of the pathology claim. Please note that this documentation will be requested from the entity that submitted the pathology claim.

Laboratory reports and X-rays from ordering physician, along with written interpretations of X-rays, tests and/or laboratory results

Letter/certificate of medical necessity (CMN) for services

Medication records/medication administration records (MAR), including strength, National Drug Code (NDC) and waste, mixing logs, infusion medication sheet and transfusion/infusion logs

Nurse or any other healthcare provider’s progress, treatment, SOAP (subjective,objective, assessment, plan) notes, dietary notes and daily notes

Obstetric/newborn services

Operating reports and records

Operative reports

Patient history

Physical exam

Physician office records: complete records, including office visit documentation, demographic/face sheet, patient history, laboratory and procedure results and all correspondence with healthcare providers, including consultation requests and reports

Physician orders

Plans of care (POC), treatment plans (tried and failed conservative treatments) and any related evaluations and updates or recertifications for the time period during which the patient was treated. The POC and recertifications should be signed by a qualified healthcare provider.

Preanesthetic evaluation

Preoperative and postoperative notes

Prescriptions

Progress notes

Psychiatric evaluation notes

Physician query (if applicable): If the facility’s coder requests additional information from the physician for clarification on documentation, he or she would submit a query to the physician.

Skilled nursing, physical therapy, occupational therapy, speech therapy, respiratory therapy and medical social worker (MSW) documentation, including notes and therapy logs that detail the number of minutes each service was provided

Test orders/results/reports including, but not limited to, pathology, radiology and laboratory (include results, when applicable)

The Outcome and Assessment Information Set (OASIS) for home health claims, completed in its entirety. All six digits of the diagnosis code must exactly match between POC, OASIS and the claim. Any correction must be applied by the end of the episode. Fields cannot contain N/A, OASIS. Fields M2200 and M0110 cannot be blank or contain N/A.

Toxicology reports

Treatment notes

Uniform billing form (UB-04)/Health Care Finance Administration Form (HCFA 1500)

Wound care assessment



Denial for Lack of Medical Records Policy

Integridad de pagos y disputas​​ ​

Integridad de pagos y disputas