CurrentHumanaPolicy CP2015002

Ordering/Referring Provider Requirements

This Humana claims payment policy governs requirements for submitting ordering or referring provider information (including name and NPI) for services that mirror Original Medicare requirements; it applies to Medicare Advantage, Commercial and Medicaid products and affects providers submitting claims to Humana.

Policy Summary

PayerHumana

PolicyOrdering/Referring Provider Requirements

Policy CodePolicy CP2015002

Change TypeNo material change

Effective Dateas written

Next Review Date2022-03

Key ActionSubmit claims for services that require orders/referrals with the ordering/referring provider's name and valid NPI.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Jan 6, 2014Original Medicare began rejecting claims

3Applicable product lines

3Example service categories

1Policy identifier

Ordering and Referral Coverage Requirements

Ordering/Referral coverage stance

Humana requires valid orders or referrals for services for which Original Medicare requires them; claims must include accurate ordering/referring provider name and NPI and be issued by a qualified healthcare provider.

An order or referral is required when Original Medicare requires one for the service provided (examples include DMEPOS, clinical laboratory/pathology, and radiology services).

The order or referral must have been issued by a qualified healthcare provider.

For Part A home health agency services, the order or referral must have been issued by a doctor of medicine (MD), doctor of osteopathy (DO) or doctor of podiatry (DPM).

Claims for services that require an order or referral must be submitted with the ordering/referring provider's name and valid NPI; the name and NPI must be accurate and valid.

Policy Summary

PayerHumana

PolicyOrdering/Referring Provider Requirements

Policy CodePolicy CP2015002

Change TypeNo material change

Effective Dateas written

Next Review Date2022-03

Key ActionSubmit claims for services that require orders/referrals with the ordering/referring provider's name and valid NPI.

SourceLink

On This Page

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Provider Responsibilities and Risk

Denial Risk

Submit claim with ordering/referring provider name and valid NPI

Submit claims for services that require an order or referral with the ordering or referring provider's name and valid NPI; the ordering/referring provider must be a qualified healthcare provider. Claims not submitted with the accurate name and valid NPI may be denied and Humana may seek reimbursement of overpayments.

Include ordering/referring provider name and NPI on the claim.
Ensure the ordering/referring provider is a qualified healthcare provider and the submitted name/NPI are accurate and valid.

Documentation Required

Keep and produce order/referral documentation on request

Maintain complete and accurate documentation of orders and referrals for services that require them and make that documentation available to Humana upon request; absence of appropriate documentation may result in denial and recovery of overpayments.

Keep original order/referral records that demonstrate the service was provided pursuant to the order/referral.
Produce order/referral documentation when requested by Humana to support payment.

Defined Terms

Qualified healthcare provider

Included provider typesDental surgeon; doctor of medicine; doctor of osteopathy; doctor of dental medicine; doctor of podiatry; optometrist (may only order DME, laboratory and X-ray services); nurse practitioner; physician assistant; certified clinical nurse specialist; clinical psychologist; intern; resident; fellow; certified nurse midwife; clinical social worker.

Optometrist limitationOptometrist may only order DME, laboratory and X-ray services.

Role in claim submissionOrdering/referring provider must be one of these qualified providers when submitting claims that require orders/referrals.

Applicable

DefinitionAn order or referral is applicable to rendered services when those services were provided pursuant to that order or referral.

ScopeApplicability ties the order/referral to the specific services actually rendered under it.

Use in denial decisionsHumana denies charges when services requiring orders/referrals are not submitted with an applicable, valid order or referral.

Overpayments

Policy definitionOverpayments are amounts paid to the provider for services that lack documentation.

RecoveryWhen appropriate, Humana plans require reimbursement of overpayments related to services requiring orders/referrals.

Documentation roleLack of documentation for orders/referrals may result in denial and overpayment recovery actions.

Refer/referral

DefinitionRefer/referral means the process of a qualified healthcare provider directing work to another provider; also known as 'certifying'.

DistinctionThis definition is distinct from plan-specific authorization processes used to authorize outpatient specialty or inpatient services.

ContextUsed when identifying who may issue orders or referrals for services that require them.

OpenPayer

Ordering/Referring Provider Requirements

Ordering and Referral Coverage Requirements

Submission Fields and Identifiers

Provider Responsibilities and Risk

Defined Terms