Medical Records Review

The following list contains procedures or services that may require the submission of member medical records for review.

Procedures or services that may require medical record review

Any service submitted with a procedure code that is not specific
Nonsurgical obesity services
Services related to growth hormone therapy
Pre-existing conditions
Physical therapy, speech therapy, occupational therapy (upon request)
Chiropractic services (upon request)
Cognitive therapy and sensory integration
Low vision rehabilitation
Alternative medicine and related services (upon request)
Investigational/experimental procedures, drugs, devices, other supplies or services (Phase I, Phase II, Phase III, and emerging/evolving technology or procedures)
Dental or oral maxillofacial services or procedures when submitted for coverage under a medical plan
Services related to patient management, coordination of care, crisis intervention, multidisciplinary assessment, or other unique community/member support/therapy services
Services for which diagnosis and procedure do not match (upon request)
Musculoskeletal services (upon request)
Any service submitted with a modifier 22 appended
Request for reconsideration of a previously denied claim when pre-authorization was required but for which no pre-authorization is currently on file
Air ambulance services
Medicare risk adjustment activities
Special investigations
Quality improvement activities
HEDIS data collection
Emergency room services
Infertility related services
Bariatric surgery
Transplant services
IV infused medications
Amniotic membrane transplantation
Capsule endoscopy
Any service submitted with a modifier 66 appended
Autism spectrum disorders services
Prosthetic devices and services
Spinal Fusion

This is not an all-inclusive list. There may be additional occasions when medical records will be requested to validate a claim or coverage.

Medical record submission

Physicians who want to submit medical records with a claim may use the above list as a guide. If medical records are not received, they will be requested at the time claims are received. There may be an associated delay in claims payments.

Note: The need to submit medical records may be dependent on the member's plan. Since not all plans have the same requirements or coverage, the provider may elect to contact Humana. Additional information is available in the following areas:

Coverage Issues

Describes the evaluation and coverage of medical procedures and devices that are being investigated or have been recently introduced.

Preauthorization List
A list of services requiring preauthorization or requesting notification.

(33.8 KB) Download Now
English

Utilization management

Utilization management may be performed by contracted vendors, and they may also request medical records for review, based on the member's plan. If the vendor issues a utilization management decision, it will be honored by Humana, and no further records will be requested. If the vendor's request for medical records is not honored, the claim may not be paid.

Submission address

The submission of medical records is not a guarantee of payment. All plan provisions still apply and services not covered by the member's plan will not be paid. Unless otherwise instructed, please direct all medical records to the following address:

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

If you have any questions about this information, please call 1-800-4HUMANA (1-800-448-6262).

The above list of procedures and services is subject to change and may be updated in the future.

^ Back to top