CurrentHumanaPolicy CP2016004

Claim Disputes

Governs timeframes and submission requirements for provider dispute requests of Humana adjudications for Medicare Advantage and Medicaid products; applies to qualified healthcare providers submitting disputes or corrected claims.

Policy Summary

PayerHumana

PolicyClaim Disputes

Policy CodePolicy CP2016004

Change TypeAdministrative/Operational update

Effective Date

Next Review Date

Key ActionA qualified healthcare provider may contest the payment, denial, or nonpayment of a claim in writing and must include member name/ID, date of service, claim number, provider identifiers, amounts, proposed correct payment, explanation, and supporting documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18 monthsin-network timeframe

180 daysout-of-network timeframe

CP2016004policy id

Published 11/2016; Revised 04/2026pub/rev

Claim Dispute Criteria and Process

Claim dispute criteria and process

Covered when ALL of the following are met:

Requester is a qualified healthcare provider licensed by the appropriate state agency to diagnose or treat sickness or injury and provide preventive services (Qualified healthcare provider).

See Definitions for term.

The request is a dispute (a written disagreement about a previous claim determination that does not change the material information submitted with the original claim).

Corrected claims that materially change submitted information are not disputes and will not be reviewed as disputes.

ALL of the following

Member name and identification number

Policy Summary

PayerHumana

PolicyClaim Disputes

Policy CodePolicy CP2016004

Change TypeAdministrative/Operational update

Effective Date

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Timeframes

Neutral billing codesmixed

Dispute submission timeframes

In-network (Medicare Advantage & Medicaid)Submit within 18 months from receipt of the original claim determination (unless contract states otherwise)

Out-of-network (Medicare Advantage)Submit within 180 days from receipt of the original claim determination

Out-of-network (Medicaid)Submit within the timeframe established by state or federal law, or 180 days from receipt of the original claim determination when state/federal law is silent

Multiple disputes per encounterMultiple provider dispute requests per provider encounter are generally unacceptable; subsequent requests must identify specific new material information to justify further review

Provider Submission Requirements

Prior Authorization

Provider dispute submission requirements (required content)

A qualified healthcare provider contesting the payment, denial, or nonpayment of a claim must submit the dispute in writing and include the following: member name and identification number; date of service; relationship of the subscriber to the patient; claim number; provider name, National Provider Identifier (NPI) and tax identification number; charge amount; payment amount; proposed correct payment amount; the difference between the amount paid and the proposed correct payment amount; a brief explanation of the basis for the contestation; and relevant supporting documentation (for example, medical records, invoice, or referral form).

Member name and identification number
Date of service
Relationship of the subscriber to the patient
Claim number
Provider name, NPI and tax identification number
Charge amount
Payment amount
Proposed correct payment amount
Difference between amount paid and proposed correct payment amount
Brief explanation of the basis for the contestation request
Relevant supporting documentation (e.g., medical records, invoice, referral form)

Key Definitions

Corrected claim

DefinitionA claim that replaces a previously submitted claim and includes material information that differs from information included in the previously submitted claim.

Material informationInformation that, because it differs from the information in the prior claim, could cause some change in reimbursement if considered.

Treatment relative to disputesCorrected claims that materially change claim information are not treated as disputes and will not be reviewed as disputes.

Dispute

DefinitionA disagreement about a previous claim determination that does not entail a change to the material information submitted for that claim.

Submission requirementThe dispute must be presented in writing, challenging the potentially adverse determination based on the previously submitted information.

Supporting materialsMedical notes, industry standards and/or Original Medicare guidelines may be used to support a dispute request.

Qualified healthcare provider

DefinitionA provider who is licensed by the appropriate state agency to diagnose or treat a sickness or bodily injury and provide preventive services.

ScopeIncludes providers with state licensure authorizing diagnosis, treatment, and preventive care as applicable to claims and dispute submissions.

Role in policyEligible to submit disputes (and, where applicable, corrected claims) consistent with contract and statutory rights.