CurrentHumanaPolicy CP2O21002

Automobile and Workplace Injuries (claims billing and reimbursement)

Governs Humana's billing requirements and claims payment procedures for healthcare services resulting from automobile and workplace injuries for Medicare Advantage and Medicaid products; affects providers submitting claims to Humana for such injuries.

Policy Summary

PayerHumana

PolicyAutomobile and Workplace Injuries (claims billing and reimbursement)

Policy CodePolicy CP2O21002

Change TypeNo material changes

Effective Date06/2022

Next Review Date

Key ActionMake reasonable efforts to determine other coverage (automobile or workers' compensation), promptly report it, and bill the automobile or workplace insurer before billing Humana MA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Advantage & MedicaidProducts covered

CP2O21002Document identifier

06/2022Publication date

RequiredMSP requirement

Coverage for Automobile and Workplace Injuries

Policy Summary

PayerHumana

PolicyAutomobile and Workplace Injuries (claims billing and reimbursement)

Policy CodePolicy CP2O21002

Change TypeNo material changes

Effective Date06/2022

Next Review Date

Key ActionMake reasonable efforts to determine other coverage (automobile or workers' compensation), promptly report it, and bill the automobile or workplace insurer before billing Humana MA.

SourceLink

On This Page

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ALL of the following

Claims for services provided due to automobile or workplace injuries are allowed for Humana Medicare Advantage plans according to applicable Medicare Secondary Payer (MSP) guidelines.
Claims for services provided due to automobile or workplace injuries are allowed for Humana Medicaid plans according to applicable state Medicaid agency requirements.
Services must meet medical necessity and reasonableness and any applicable referral or authorization requirements.
Providers must make all reasonable efforts to determine whether there is other coverage (automobile or workers' compensation) and must promptly report any such coverage to Humana; providers must bill the automobile or workplace insurer before billing Humana MA when applicable.
Providers must promptly forward to Humana any determination by an automobile or workplace insurance plan regarding a claim for a Humana enrollee's injuries; failure to promptly fulfill these requirements could affect Humana's disposition of a claim.

Submission documentation requirements

Required claim documentation and form entries when other primary coverage (auto or workers' compensation) is identified. Include the listed form fields and attach supporting documents when available.

If automobile insurance is identified (CMS-1500)

Enter 'yes' in box 10-B.
Enter the accident date in field 14.
Enter all diagnosis codes in section 21.
Include a copy of the check from the primary insurance carrier.
Attach when available
- Copy of the explanation of benefits (EOB) from the primary insurance carrier.
- Personal injury protection (PIP) worksheet.
- Copy of the exhaustion denial letter from the primary insurance carrier.
- Statement from the patient indicating no PIP coverage, if applicable.

If automobile insurance is identified (UB-04)

Enter occurrence code 01 or 02, as applicable, and the accident date in fields 33-35.
Enter value code 14 in fields 39-41.
Enter all diagnosis codes in fields 67-76.
Include a copy of the check from the primary insurance carrier.
Attach when available
- Copy of the EOB from the primary insurance carrier.
- Statement from the patient indicating no PIP coverage, if applicable.

If workers' compensation is identified (CMS-1500)

Enter 'yes' in box 10-B.
Enter the accident date in field 14.
Enter all diagnosis codes in section 21.
Include a copy of the check from the primary insurance carrier.
Attach when available
- Copy of the EOB from the primary insurance carrier.
- Statement from the patient confirming that their employer does not provide workers' compensation coverage.

If workers' compensation is identified (UB-04)

Enter occurrence code 04 and the accident date in fields 33-35.
Enter condition code 02, 05, or 77, as applicable, in fields 18-28.
Enter value code 15 or 41, as applicable, in fields 39-41.
Enter all diagnosis codes in fields 67-76.
Include a copy of the check from the primary insurance carrier.
Attach when available
- Copy of the EOB from the primary insurance carrier.

Note: Medicare benefits are secondary regardless of whether the patient wishes to file a workers' compensation claim. Humana may deny a claim submitted without the required information above.

Claim Form Fields and Codes

CMS-1500 (or electronic equivalent)mixed

Box 10-B	Enter 'yes' for accident-related claims
Field 14	Enter accident date
Section 21	Enter all diagnosis codes
Attachments	Copy of primary insurer check; EOB; PIP worksheet if available; exhaustion denial letter; patient statement re: no PIP coverage

UB-04: Automobile accident / third-party liability (not workers' compensation)mixed

Occurrence code 01/02	Enter occurrence code 01 or 02 as applicable in fields 33-35 and the accident date
Fields 33-35	Occurrence code and accident date
Value code 14	Enter value code 14 in fields 39-41 (payments from primary/third-party)
Diagnosis fields	Enter all diagnosis codes in fields 67-76
Attachments	Copy of primary insurer check; Copy of EOB; exhaustion denial letter; patient statement re: no PIP coverage (if applicable)

UB-04: Workers' compensation situationsmixed

Occurrence code 04	Enter occurrence code 04 and accident date in fields 33-35
Condition code 02/05/77	Enter condition code 02, 05, or 77 as applicable in fields 18-28
Value code 15/41	Enter value code 15 or 41 as applicable in fields 39-41 (workers' compensation/other payments)
Fields 33-35	Occurrence code 04 and accident date
Fields 18-28	Condition code for workers' compensation or related employer coverage indicators
Fields 39-41	Value code for payment amounts (15 or 41)
Diagnosis fields	Enter all diagnosis codes in fields 67-76
Attachments	Copy of primary insurer check; Copy of EOB; exhaustion denial letter; patient statement confirming employer does not provide workers' compensation coverage (if applicable)
Note	Medicare benefits are secondary regardless of whether the patient files a workers' compensation claim. Humana may deny claims submitted without required information.

Provider Responsibilities and Risks

Note

Provider responsibilities for identifying and reporting other coverage

Humana Medicare Advantage (MA) plans allow claims for healthcare services provided due to automobile and workplace injuries according to applicable Medicare Secondary Payer (MSP) guidelines. A provider must make all reasonable efforts to determine whether there is other coverage for an automobile or workplace injury (for example, automobile or workers' compensation insurance); promptly report any such other coverage in claims submitted to Humana; bill the patient’s automobile or workplace injury insurance plan, if applicable, before billing the patient’s Humana MA plan; and promptly forward to Humana any determination by an automobile or workplace insurance plan made with respect to a claim for a Humana MA enrollee’s injuries. A provider’s failure to promptly fulfill any requirement could affect Humana’s disposition of a claim after initial receipt and/or after initial adjudication.

Documentation Required

What to include on claims

If a provider identifies automobile insurance, include the required MSP information when submitting a claim to Humana. For UB-04 claims (or electronic equivalent) include: occurrence code 04 and accident date in fields 33-35; condition code 02, 05, or 77 as applicable in fields 18-28; value code 15 or 41 as applicable in fields 39-41; all diagnosis codes in fields 67-76. Attach a copy of the check from the primary insurance carrier and, if available, the EOB from the primary carrier, a patient statement confirming lack of employer workers' compensation, or an exhaustion denial letter from the primary carrier. Note: Medicare benefits are secondary regardless of whether the patient wishes to file a workers' compensation claim.

Denial Risk

Denial risk for missing MSP information

Humana may deny a claim for healthcare services provided due to an automobile or workplace injury if the claim is submitted without the required MSP information (see required fields and attachments above). Failure to include required other-coverage information may result in claim denial.

Key Terms

MSP — Medicare Secondary Payer (MSP)

DefinitionMedicare Secondary Payer (MSP)

ScopeHumana Medicare Advantage plans follow applicable MSP guidelines for claims related to automobile and workplace injuries.

Provider obligationProviders must make reasonable efforts to determine other coverage (automobile or workers' compensation) and promptly report identified coverage to Humana.

Billing orderProviders must bill the automobile or workers' compensation insurer before billing the member's Humana MA plan.

ConsequenceFailure to promptly provide required MSP information may affect Humana's disposition of a claim and may result in denial.

Claim form identifiers — CMS-1500 / UB-04

CMS-1500: Auto/Work injury indicatorEnter 'yes' in box 10-B to indicate an automobile/workplace injury.

CMS-1500: Accident dateEnter the accident date in field 14.

CMS-1500: Diagnosis codesEnter all diagnosis codes in section 21.

UB-04: Automobile occurrence codesEnter occurrence code 01 or 02 and the accident date in fields 33-35 for automobile accidents.

UB-04: Workers' compensation codesEnter occurrence code 04 and accident date in fields 33-35; enter condition code 02, 05, or 77 as applicable in fields 18-28; enter value code 15 or 41 as applicable in fields 39-41.

UB-04: Diagnosis codesEnter all diagnosis codes in fields 67-76.

Supporting documentationAttach copy of the primary payer's check and, if available, the EOB, exhaustion denial letter, PIP worksheet (for auto), or patient statement regarding lack of PIP/workers' comp coverage.