CurrentHumanaPolicy CP2023011

Transition Period Billing for an Active Course of Treatment

Govern billing and claims submission practices for services that are part of an active course of treatment that began prior to a member's enrollment in Humana Medicare Advantage plans, affecting providers submitting claims for those new enrollees.

Policy Summary

PayerHumana

PolicyTransition Period Billing for an Active Course of Treatment

Policy CodePolicy CP2023011

Change TypeNo material changes

Effective Date01/01/2024

Next Review Date

Key ActionDo not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment for active courses of treatment; append modifier TZ on professional and outpatient claims and condition code 9T on inpatient claims to facilitate processing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daystransition period duration

CP2023011policy id

Medicare Advantageapplicability

Transition Period Coverage Criteria

Transition period coverage criteria

Humana will process claims for services that are part of an active course of treatment during the first 90 days of a new Medicare Advantage (MA) enrollment without requiring prior authorization for basic Medicare benefits, subject to plan coverage and documentation.

Member is enrolled in a Humana Medicare Advantage plan (excluding PFFS).

Applies to MA plans other than Private Fee‑For‑Service (PFFS).

Service was furnished during the transition period (the first 90 days of the member's enrollment).

Transition period = first 90 days of that specific enrollment.

Service was part of an active course of treatment that began before the member's enrollment in the Humana MA plan.

Active course of treatment = patient actively seeing the provider and following the course of treatment.

Policy Summary

PayerHumana

PolicyTransition Period Billing for an Active Course of Treatment

Policy CodePolicy CP2023011

Change TypeNo material changes

Effective Date01/01/2024

Next Review Date

SourceLink

On This Page

ALL of the following

Append modifier TZ on professional and outpatient facility claims for each service that was part of the active course of treatment during the 90‑day transition period.
Modifier TZ identifies services furnished during the transition period.
Report condition code 9T on inpatient facility claims for each service that was part of the active course of treatment during the 90‑day transition period.
Condition code 9T identifies inpatient services furnished during the transition period.

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization exception for 90‑day transition — append TZ/9T to help processing

Pursuant to 42 C.F.R. § 422.112(b)(8)(i)(B), Humana will not require prior authorization for basic Medicare benefits during the first 90 days of a new member's enrollment when services are part of an active course of treatment that started before enrollment. Providers are encouraged to append modifier TZ on professional and outpatient facility claims and condition code 9T on inpatient facility claims to facilitate accurate claims processing for services furnished during this transition period.

Do not apply these transition coding provisions for Humana MA PFFS plan members.
Only use TZ on professional and outpatient facility claims; use 9T on inpatient facility claims.

Documentation Required

Documentation review and plan exclusions for TZ/9T

If a provider does not append the recommended modifier TZ or condition code 9T on a claim for a new Humana MA enrollee, Humana may evaluate medical record documentation submitted with the claim to determine whether the service was part of an active course of treatment. Do not report TZ or 9T on Humana commercial or Humana Medicaid claims.

Humana may request or review medical records to substantiate an active course of treatment when TZ/9T is not present.
Do not use TZ/9T for Humana commercial, Humana Medicaid, or PFFS plan members.

Definitions and Term Clarifications

Active course of treatment

DefinitionA course of treatment in which a patient is actively seeing the provider and following the course of treatment.

Related termCourse of treatment: A prescribed order or ordered course of treatment for a specific individual with a specific condition that is outlined and decided upon ahead of time with the patient and the provider.

ApplicationUsed to identify services that may qualify for transition-period processing when the course began prior to Humana Medicare Advantage enrollment.

Condition code 9T

CodeCondition code 9T

DefinitionIndicates the service is part of an active course of treatment that began before enrollment into the member's current Humana Medicare Advantage plan and was provided during the transition period.

UseReport on inpatient facility claims to identify services furnished during the 90-day transition period.

Modifier TZ

ModifierTZ

UseAppend on professional and outpatient facility claims to facilitate transition-period processing.

Transition period

DurationThe first 90 days of the member's specific enrollment period.

ScopeApplies to services furnished during an enrollment when the service was part of an active course of treatment that began before enrollment.

PurposeEnsures continuity of care by allowing claims processing without prior authorization for basic Medicare benefits during this period, subject to plan coverage and documentation.

Professional claim

FormCMS-1500 form or its electronic equivalent

DefinitionCharges for professional services submitted on the CMS-1500 form or its electronic equivalent.

ContextProviders are encouraged to append modifier TZ on professional claims when the service is part of an active course of treatment during the transition period.

Outpatient facility claim

FormUB-04 form or its electronic equivalent

DefinitionCharges for facility services submitted on the UB-04 form, or its electronic equivalent, submitted with a type of bill code that, for Original Medicare, would not be used for 'Part A' payment (outpatient).

Coding guidanceAppend modifier TZ on outpatient facility claims when the service is part of an active course of treatment during the transition period.

Inpatient facility claim

FormUB-04 form or its electronic equivalent

DefinitionCharges for facility services submitted on the UB-04 form, or its electronic equivalent, submitted with a type of bill code that, for Original Medicare, would be used for 'Part A' payment (inpatient).

Coding guidanceReport condition code 9T on inpatient facility claims when the service is part of an active course of treatment during the transition period.

PFFS

DefinitionPrivate fee-for-service (PFFS) is a specific type of Medicare Advantage plan, distinct from other MA plan types.

ApplicabilityThese transition coding provisions do not apply to PFFS plan members.

ImplicationDo not use modifier TZ or condition code 9T for PFFS members; Humana's transition processing protections are for non-PFFS MA products.

OpenPayer

Transition Period Billing for an Active Course of Treatment

Transition Period Coverage Criteria

Transition Period Claim Indicators and Codes

Provider Actions, Prior Authorization & Documentation

Definitions and Term Clarifications

TZ	Modifier indicating service is part of an active course of treatment that began before enrollment and was provided during the transition period (professional and outpatient facility claims)
9T	Condition code indicating service is part of an active course of treatment that began before enrollment and was provided during the transition period (inpatient facility claims)