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Summary of “key” Humana Settlement provisions

Coding rules (continued)

  • No CPT modifier 51 exempt CPT codes are subject to the multiple procedure reduction logic or rule.

  • “Add-on” codes, as designated by CPT, will be recognized and eligible for payment as separate codes and shall not be subject to the multiple procedure logic or rule.

  • Supervision and interpretation of radiologic guidance

    • (e.

      g., fluoroscopic, ultrasound or mammographic) CPT codes are separately identifiable and eligible for payment.

  • A CPT code appended with a CPT modifier 59 will be recog- nized and separately eligible for payment to the extent that it designates a distinct or independent procedure performed on the same day by the same physician and that there is not a more appropriate CPT recognized modifier to append to the code(s).

  • No global period for surgical procedures will be longer than the period designated by the Centers for Medicare & Medicaid Services.

  • Humana shall not automatically change a code to one reflecting a reduced intensity of service when such CPT code is one among or across a series that includes, without limitation, codes that differentiate among simple, intermediate and complex, complete or limited, and/or size.

  • Humana has agreed to pay a fee for the administration of vaccines and injectibles by a physician.

  • Humana will pay for newly recommended vaccines as of the effective date of a recommendation made by any of the following: the U.S. Preventive Services Task Force, the American Academy of Pediatrics and the Advisory Committee on Immunization Practices.

Prompt payment requirements

  • Beginning one year following the “effective date of September 28, 2006” of the Settlement, “complete claims” for covered services submitted electronically must be paid (mail a check or make an electronic funds transfer) within 15 calendar days of receipt.

  • Interest will be paid at 6 percent per annum on delayed claims.

Disclosure of fee schedule information, claim coding and payment policies

  • The complete fee information showing the applicable fee schedule amount shall be made available to all contracted physicians via hard copy, CD-ROM or electronically.

  • Copies of contracts will be provided to physicians upon written request.

  • “Payment in full” or other restrictive endorsement on a payment by Humana is not binding and can be appealed.

  • Humana will disclose the identities of those entities that are not subsidiaries to which it provides access to its network of participating physicians. Humana may or may not adjudicate the claims for the entities, but Humana does not provide the explanation of benefits or remittance advice.

Overpayment recovery

  • Overpayment recovery efforts will not be initiated by Humana more than 18 months from the date original payment was received by the physician.

  • A 30-day written notice will be provided to the physician prior to initiating an overpayment recovery effort.

Medically necessary or medical necessity definition

  • No retroactive retraction of a pre-certified medically necessary determination shall occur.

  • Humana accepts the following definition of medical necessity or comparable term:

“Medically Necessary” or “Medical Necessity” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a) in accordance with generally accepted standards of medical practice; b) clini- cally appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and c) not primarily for the convenience of the patient, physician or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diag- nostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer- reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations, the views of physicians practicing in relevant clinical areas and any other relevant factors.

New physician credentialing

  • New physician group members will be credentialed (including, as relevant, licensure and hospital privilege) within 90 days of receipt of the application. Physicians also can submit an application prior to their employment.

  • Humana will only require previously credentialed physicians to submit additional information based upon a change in employment or location.

For more information and resources, there are three easy ways to contact the AMA Private Sector Advocacy (PSA) unit:

  • Call (800) 262-3211 and ask for AMA-PSA.

  • Fax information to (312) 464-5541.

  • Visit www.ama-assn.org/go/psa to access the

AMA-PSA Web site.

© 2006 American Medical Association

GEA:06-1204:2.5M:12/06

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