Gender-Specific Services for Transgender or Intersex Members
Guidance on billing and claims reporting when providing medically necessary gender‑specific services to transgender or intersex members for Humana Medicare Advantage and Commercial products; intended for healthcare providers submitting claims.
No material clinical or coverage changes in this revision.
Coverage Guidance
Coverage guidance
Humana's position on coverage and claim processing for gender-specific services:
ALL of the following
- Humana allows a medically necessary gender-specific service for transgender or intersex members when the service is not otherwise excluded.
- Recognition of condition code 45 (facility) and modifier KX (professional) on claims is accepted as an indication that the service may be medically necessary despite an apparent conflict between reported gender and the gender-specific service.
- Providers are encouraged to follow appropriate Medicare Program guidance for correctly coding a gender-specific service and diagnosis for a transgender or intersex member; report condition code 45 on facility claims (UB-04) and include modifier KX on professional claims (CMS-1500) when appropriate.
- Payment remains subject to other plan requirements including medical necessity, reasonableness, and any referral/authorization requirements.
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