CurrentHumanaPolicy CP2018010

Missed Appointments

This Humana claims payment policy explains provider expectations and Humana's stance on charging patients for missed appointments for Medicare Advantage and Commercial products; it affects providers billing Humana for such fees.

Policy Summary

PayerHumana

PolicyMissed Appointments

Policy CodePolicy CP2018010

Change TypeNo material change

Effective Date

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.

no reimbursementMedicare Advantage

no reimbursementCommercial

08/2019, 02/2023Publication / Revision

MA & CommercialApplicability

Missed Appointment Coverage Stance

Missed appointment coverage criteria

Humana's coverage stance and requirements for missed appointment fees are:

Humana does not reimburse missed appointment charges for either Medicare Advantage or Commercial plans; missed appointment fees should not be billed to Humana and will be denied as not covered.

Providers may charge patients directly for missed appointments only as permitted by applicable rules; for Commercial members this is allowed unless prohibited by state law, the member's plan certificate, Humana's provider manual, or other applicable standard.

For Medicare Advantage members, any missed appointment policy must be applied equally to Medicare beneficiaries and non‑Medicare patients; the fee must be the same for both groups.

A missed appointment fee is considered compensation for a missed business opportunity and not a charge for a health care service.

Policy Summary

PayerHumana

PolicyMissed Appointments

Policy CodePolicy CP2018010

Change TypeNo material change

Effective Date

Next Review Date

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

SourceLink

On This Page

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Billing and Submission Guidance for Providers

Billing Rule

Do not bill Humana for missed appointment fees

Do not bill Humana for missed appointment fees. Humana will deny any missed appointment charge as not covered under the member's plan; providers may charge patients directly for missed appointments per applicable rules and state law.

If a provider submits a missed appointment charge to Humana, Humana will deny the charge as not covered under the member's plan.

Documentation Required

MA members: apply missed appointment policy equally and do not bill Humana

For Medicare Advantage members, any missed appointment policy must be applied equally to Medicare beneficiaries and non‑Medicare patients; the fee must be the same for both and must not be billed to Humana.

A missed appointment fee is not considered a charge for a health care service but compensates the provider for a missed business opportunity.
Hospitals may not charge a registered inpatient for missing an outpatient appointment (charging a registered inpatient would violate 42 CFR 489.22).
Humana MA plans do not reimburse missed appointment charges; billing Humana will result in denial.

Documentation Required

Commercial members: may charge patient but do not bill Humana

For Commercial members, providers may charge a missed appointment fee unless prohibited by state law, the member's plan certificate, Humana's provider manual, or other applicable standard; these fees should not be billed to Humana.

Humana commercial plans do not reimburse missed appointment charges; submission to Humana will be denied as not covered.

Key Definitions

Missed appointment fee — definition and key points

DefinitionA fee imposed by a provider to compensate for a missed business opportunity when a patient fails to attend a scheduled appointment; not considered a charge for a health care service.

ApplicabilityApplies to appointments for Medicare Advantage members; providers must apply the policy equally to Medicare beneficiaries and non‑Medicare patients.

Fee parity requirementThe missed appointment fee must be the same for Medicare beneficiaries and patients who are not Medicare beneficiaries.

Hospital outpatient restrictionA hospital may charge for a missed outpatient appointment only if the patient is not a registered inpatient; charging a registered inpatient violates 42 CFR 489.22.

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

OpenPayer

Missed Appointments

Missed Appointment Coverage Stance

Billing Codes and Status

Billing and Submission Guidance for Providers

Key Definitions