CurrentHumanaPolicy CP2021002

Automobile and Workplace Injuries

Defines Humana's billing requirements and reimbursement practices for claims arising from automobile and workplace injuries for Medicare Advantage and Medicaid products; applies to providers submitting claims for Humana members.

Policy Summary

PayerHumana

PolicyAutomobile and Workplace Injuries

Policy CodePolicy CP2021002

Change TypeNo material changes

Effective Date06/2022

Next Review Date

Key ActionMake all reasonable efforts to determine other coverage (automobile or workers' compensation), promptly report identified coverage to Humana, bill primary payer before Humana, and forward primary payer determinations to Humana.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS form reqsCMS-1500 and UB-04 data/attachment requirements

MSP appliesMSP billing rules apply to MA plans

Applies toMedicare Advantage and Medicaid Products

Coverage Criteria for Automobile and Workplace Injuries

Coverage criteria for automobile and workplace injury claims

Covered when ALL of the following are met:

Claims for automobile and workplace injuries are allowed for Humana Medicare Advantage and Humana Medicaid plans when submitted in accordance with applicable MSP and state Medicaid requirements.

Provider has made all reasonable efforts to determine whether other coverage (automobile or workers' compensation) exists and has documented those efforts.

If other primary coverage is identified, the provider has billed the primary automobile or workers' compensation payer before billing Humana and has promptly reported the identified coverage to Humana.

The provider has forwarded to Humana any determination made by the primary automobile or workers' compensation insurer regarding the claim.

Policy Summary

PayerHumana

PolicyAutomobile and Workplace Injuries

Policy CodePolicy CP2021002

Change TypeNo material changes

Effective Date06/2022

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.

Form Data, Codes, and MSP Rule

Form data and condition/value/occurrence codesmixed

Occurrence codes 01, 02, 04	Use occurrence codes 01 or 02 for automobile; 04 for workers' compensation on UB-04
Value codes 14, 15, 41	Use value code 14 for auto (UB-04); 15 or 41 as applicable for workers' comp (UB-04)
Condition codes 02, 05, 77	Enter condition code 02, 05, or 77 as applicable (UB-04 fields 18-28)
CMS-1500 box 10-B = yes	Enter 'yes' in box 10-B for auto or workers' comp on CMS-1500

inv-03: Medicare secondary payer rule — Medicare benefits are secondary regardless of member filing workers' compensation claim

MSP ruleMedicare benefits are secondary regardless of whether the patient wishes to file a workers' compensation claim.

UB-04 occurrence codeEnter occurrence code 04 and accident date in fields 33 - 35 for workplace injuries.

UB-04 condition codesEnter condition code 02, 05, or 77, as applicable, in fields 18 - 28.

UB-04 value codesEnter value code 15 or 41, as applicable, in fields 39 - 41.

Documentation attachmentsAttach copy of primary carrier check, EOB, exhaustion denial letter, and patient statement about employer WC if available.

Provider Responsibilities and Denial Risks

Documentation Required

Primary Payer Identification and Reporting

Make all reasonable efforts to determine whether there is other coverage for an automobile or workplace injury (e.g., automobile or workers' compensation), promptly report any identified coverage in claims submitted to Humana, bill the primary automobile/workers' compensation plan before billing Humana, and forward any determination from the primary insurer to Humana.

Make reasonable efforts to determine other coverage for automobile or workplace injuries.
Promptly report identified coverage in claims submitted to Humana.
Bill the primary automobile or workers' compensation plan prior to billing Humana MA.
Forward primary payer determinations to Humana.

Denial Risk

Potential Denial Risk for Missing Information

Humana may deny a claim for services related to an automobile or workplace injury if the claim is submitted without the required automobile/workers' compensation information and supporting documentation.

For UB-04: occurrence/condition/value codes, diagnosis codes, and attachments (EOB, check from primary carrier, exhaustion denial, patient statement) as listed in the policy.
Failure to promptly provide required information may affect Humana's disposition of a claim after initial receipt or adjudication.

Definitions

inv-06: MSP — Medicare Secondary Payer definition/notes

DefinitionMedicare Secondary Payer (MSP): Medicare (including MA plans) is secondary payer when another party (e.g., automobile or workers' compensation) is liable for the claim.

Provider obligationsMake all reasonable efforts to determine other coverage, bill primary automobile/workers' compensation before Humana, and promptly forward primary payer determinations to Humana.

Claim risk for missing infoHumana may deny claims for automobile or workplace injuries if required MSP-related information and attachments are not submitted.

Form reporting expectationProviders are expected to abide by MSP billing requirements when submitting claims to Humana MA plans.