CurrentHumanaPolicy CP2013101

Transitional Care Management (TCM) Payment Policy

Humana's claims payment policy for Transitional Care Management (TCM) services for Medicare Advantage and Commercial products, describing reimbursement rules, eligible discharge settings, provider requirements, and billing instructions that affect providers submitting TCM claims.

Policy Summary

PayerHumana

PolicyTransitional Care Management (TCM) Payment Policy

Policy CodePolicy CP2013101

Change TypeNo material change

Effective Date01/2013

Next Review Date

Key ActionSubmit a claim showing discharge from an approved facility setting and document required CMS TCM elements to substantiate reimbursement for one professional TCM service per discharge.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30-dayservice period for TCM reimbursement

7d / 14dface-to-face timing (99496 / 99495)

onecharges reimbursed per discharge

2 business daysrequired post-discharge communication

Transitional Care Management Coverage Criteria

TCM coverage criteria

Humana reimburses one professional TCM service per discharge when CMS requirements and policy criteria are met.

A claim showing discharge from one of the following facility settings must be received: hospital outpatient observation or partial hospitalization; inpatient psychiatric hospital; inpatient acute care hospital; inpatient rehabilitation facility; partial hospitalization at a community mental health center; long-term care hospital; or skilled nursing facility.

Only one professional TCM charge will be reimbursed per discharge: Humana reimburses the first TCM charge received for the 30-day service period that meets all requirements; subsequent TCM charges for the same 30-day service period will not be reimbursed.

Communication with patient or caregiver within 2 business days of discharge is required (direct contact by telephone or electronic means).

ALL of the following

Policy Summary

PayerHumana

PolicyTransitional Care Management (TCM) Payment Policy

Policy CodePolicy CP2013101

Change TypeNo material change

Effective Date01/2013

Next Review Date

Key ActionSubmit a claim showing discharge from an approved facility setting and document required CMS TCM elements to substantiate reimbursement for one professional TCM service per discharge.

SourceLink

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CPT Codes and Timing Requirements

TCM CPT codes and required elementsCPTCovered

99495	TCM: communication within 2 business days, moderate medical decision making, face-to-face within 14 days
99496	TCM: communication within 2 business days, high medical decision making, face-to-face within 7 days

Face-to-face timing — CPT 99496 within 7 days; CPT 99495 within 14 days.

Face-to-face timingCPT 99496: face-to-face visit within 7 days of discharge; CPT 99495: face-to-face visit within 14 days of discharge.

Place of serviceFace-to-face visit must be furnished in office, outpatient setting, or patient's residence (telehealth allowed per Humana telehealth policy).

Date of service reportingProvider must report the date of service as the date of the face-to-face visit.

Billing, Documentation, and Prior Authorization Notes

Prior Authorization

Prior authorization/substantiation: one TCM charge per discharge; discharge claim required

Humana may reimburse one professional Transitional Care Management (TCM) charge per discharge when CMS TCM requirements and this policy’s criteria are met. To substantiate TCM necessity, the claim must show discharge from one of the listed facility settings (hospital outpatient observation/partial hospitalization, inpatient psychiatric hospital, inpatient acute care hospital, inpatient rehabilitation facility, partial hospitalization at a community mental health center, long-term care hospital, or skilled nursing facility). Providers must follow all CMS TCM requirements referenced in the policy.

Only the first TCM charge received for the 30‑day service period that meets requirements will be reimbursed.
A claim showing discharge from an approved facility setting must be received to substantiate the professional TCM claim.
TCM face‑to‑face services must be rendered by an MD, DO, or an approved NPP, and portions provided by clinical staff must meet CMS "incident to" and state scope of practice requirements.

Key Term Definitions

CPT 99495 — Required elements

Required communicationDirect contact (telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.

Medical decision makingAt least a moderate level of medical decision making during the service period is required.

Face-to-face timingFace-to-face visit must occur within 14 calendar days of discharge.

CPT 99496 — Required elements

Required communicationDirect contact (telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.

Medical decision makingHigh level of medical decision making during the service period is required.

Face-to-face timingFace-to-face visit must occur within 7 calendar days of discharge.

Incident to — CMS requirements

Definition'Incident to' are CMS requirements that must be met for a physician or nonphysician practitioner to bill for a service or supply provided by clinical staff.

Supervision and scopeServices furnished by clinical staff must be under the general supervision of the billing physician or NPP and comply with state scope of practice and 42 CFR 410.26(a)(1).

ApplicabilityApplies to portions of TCM services rendered by clinical staff; clinical staff must meet auxiliary personnel requirements.