CurrentHumanaPolicy CP2O18010

Missed Appointments — Claims Payment Policy

Defines Humana's claims payment stance on provider-imposed missed appointment charges for Medicare Advantage and Commercial members and explains billing expectations for providers submitting such charges.

Policy Summary

PayerHumana

PolicyMissed Appointments — Claims Payment Policy

Policy CodePolicy CP2O18010

Change TypeNo material change

Effective DateAug 1, 2019

Next Review Date

Key ActionDo not bill Humana for missed appointment fees; Humana will deny such charges as not covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not reimbursedMA stance

Provider may chargeCommercial stance

Do not bill HumanaBilling instruction

42 CFR 489.22Regulatory ref

Coverage Criteria for Missed Appointment Fees

Medicare Advantage missed appointment policy

Medicare Advantage

Humana MA plans do not reimburse for missed appointment fees; such charges should not be billed to Humana and will be denied as not covered.

Providers must apply missed appointment policies equally to Medicare beneficiaries and non-Medicare patients; the fee must be the same for Medicare beneficiaries and patients who are not Medicare beneficiaries (Medicare Claims Processing Manual, Ch.1 §30.3.13).

Hospitals may not charge a registered inpatient a missed appointment fee for outpatient appointments while the patient is receiving inpatient services (42 CFR 489.22).

Commercial missed appointment policy

Commercial

Policy Summary

PayerHumana

PolicyMissed Appointments — Claims Payment Policy

Policy CodePolicy CP2O18010

Change TypeNo material change

Effective DateAug 1, 2019

Next Review Date

Key ActionDo not bill Humana for missed appointment fees; Humana will deny such charges as not covered.

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.

Provider Billing and Collection Actions

Billing Rule

Do not bill Humana for missed appointment fees; observe MA billing equity and inpatient restriction

Do not bill Humana for missed appointment fees; Humana will deny such charges as not covered. For Medicare Advantage members the fee must be applied equally to Medicare beneficiaries and non‑Medicare patients and hospitals may not charge registered inpatients for missed outpatient appointments (42 CFR 489.22). Commercial enrollees may be charged by the provider unless prohibited by state law, the member's plan certificate, Humana's provider manual, or other applicable standards.

Humana MA plans do not reimburse missed appointment fees; charges submitted to Humana will be denied as not covered (MA).
Missed appointment fees must be the same for Medicare beneficiaries and non‑Medicare patients per Medicare Claims Processing Manual standards.
Hospitals may not charge a registered inpatient a missed appointment fee for outpatient appointments (42 CFR 489.22).
Humana commercial plans do not reimburse missed appointment fees; providers may bill and collect from commercial members only if permitted by state law, plan certificate, Humana provider manual, or other standards.

Definitions and Regulatory Notes

inv-05: Missed appointment fee

DefinitionMissed appointment fee: a fee imposed by a provider to compensate for a missed business opportunity; not considered a charge for a health care service.

Humana MA reimbursement stanceHumana MA plans do not reimburse missed appointment charges; such fees should not be billed to Humana and will be denied as not covered.

Billing instructionIf a provider submits a missed appointment charge to Humana for a MA enrollee, Humana will deny the charge as not covered under the member's MA plan.

Billing equity requirementProviders must apply missed appointment policies equally to Medicare beneficiaries and non‑Medicare patients; the fee must be the same for both groups per Medicare Claims Processing Manual guidance.

inv-06: Hospital inpatient restriction

Restriction summaryHospitals may not charge a registered inpatient a missed appointment fee for outpatient appointments while the patient is receiving inpatient services (violates 42 CFR 489.22).

Applicable settingRestriction applies to charges for missed appointments in the hospital's outpatient department when the patient is an admitted inpatient.

Regulatory referenceReference: 42 CFR 489.22 (hospital inpatient protections).

OpenPayer

Missed Appointments — Claims Payment Policy

Coverage Criteria for Missed Appointment Fees

Billing Codes and Coding Guidance

Provider Billing and Collection Actions

Definitions and Regulatory Notes