Humana IOP H-code
In May of 2016, Humana informed that they would no longer accept the Chemical Dependency HCPCS code H0015 for IOP claims because it was considered a “Medicare” code. It had been explained that this policy became effective in January of 2016 and from then on we were supposed to only use the Mental Health HCPCS code S9480 for IOP. Due to this behavioral health programs began receiving refund requests for all IOP claims that had been billed with code H0015; which required programs to rebill all IOP claims from the beginning of 2016 with S9480. With that, Humana sent most of the rebilled claims to their Special Investigations Unit in order to request medical records and prove that the treatment was medically necessary and performed as billed. Nine months later approximately 30% of those rebilled claims are still under “special investigation”, despite weekly follow-up with Humana’s Special Investigations Liaison requesting an expedited review of the claims processing.
Eventually, programs started receiving refund requests for H-code claims that were billed in 2015 even though Humana had told us that the code became effective January 1st, 2016. This of course triggered programs to begin contacting Humana’s Recoveries Department to tell them that the 2015 refund requests were invalid due to the fact that the H-code policy did not become effective until 2016. 
As we were disputing these, Humana explained that the policy actually became effective in September of 2015, then later stated that the policy has actually always been in effect. Overall this created a contradictive and confusing problem that has been difficult to manage.
The next step with these claims was to get Humana to send written documentation of said policy in order for them to prove to us that their refund requests were in fact valid. Obtaining the documentation has been also difficult. In December of 2016, we spoke with a Humana representative on the phone that took us to the specific place on their website where it states the policy and when it went into effect. The policy states “With the exception of HCPCS codes H0031, H0032, H2012 and H2019, HCPCS “H codes” H0001-H2037 will not be reimbursed.” Notification date on the policy was 6/17/2016 and the effective date listed is 9/19/2016. This meant that all of the H-code claims that Humana had issued refund requests and recoupments on prior to September 19th, 2016 were invalid. We were told by said representative that there was a “glitch/issue” in Humana’s system in which they accidentally had the effective date listed as 9/16/2015, one year prior to when it actually went into effect.[/vc_column_text][/vc_column][/vc_row][vc_row css=".vc_custom_1486708564901{margin-top: 10px !important;}"][vc_column][vc_column_text]
A Few Numbers To Look At:
Statistics since we have started getting the refund requests/recoupments reversed or the S-code paid:
- $484,769.02: Total refund requests/recoupments received from Humana on this issue (204 claims)
- $206,334.96: S-code claims through “Special Investigations” that have been able to get paid (89 claims – 62% of completed)
- $134,117.60: H-code refund requests/recoupments we have gotten reversed (57 claims – 39% of completed)
- $340,452.56: Total resolved (146 claims – 70% of total requests received)
- $144,316.46: Still working on getting S-code paid or H-code refund request/recoupment reversed (58 claims – 30% of total requests received)
For more information on managing claims effectively give us a shout!
Elevated Billing Solutions
