Humana Audit Program Updates

Humana Pharmacy Solutions Audit Uniform Prescriber Statement Form

• One page document necessary to appeal various discrepancy codes
• New as of July 1, 2021
• Replaces the Prescriber Statement that was required to be handwritten on prescriber pre-printed prescription pads
• Prescriber statements will not be accepted during appeal unless submitted on this form

Humana Pharmacy Solutions Audit Discrepancy Code List

• Eight page document that describes each discrepancy code, identifies the financial outcomes, and acceptable appeal materials (coined “mitigating documentation”)
• There are no longer references to the Corrected Values Form
• Pharmacies may submit documentation to appeal discrepancies that otherwise would result in a $5.00 Administrative Penalty (e.g. Incorrect Origin Code IOCP)
• Some discrepancies may now be appealed with electronic date/time stamped notes from your pharmacy system
• There are now 4 codes describing different Invalid Signature Logs (instead of 1) that provides more appeal flexibility
• Missing Signature Logs (MSL) may now be appealed with original signature logs rather than having to get a Member Statement (in some states)
• Wrong Hard Copy (WHC) may now be appealed with a Prescriber Statement
• Member Statements (PAAS National^® often calls these “Patient Affidavits”) that are signed by someone other than the patient must include signature, print name and relationship to the patient

Humana Pharmacy Solutions Audit and Claim Review Guide

• Twenty-one page document explains Humana audit program, processes and documentation requirements
• Section 2.1.4 explains that pharmacies will be assessed a 25% penalty (capped at $10,000) for late submissions for desk audits – if no response is submitted by the post-audit (appeal) due date, then Humana may assess 100% claim recoupment
• Section 2.2 explains that onsite audits may review up to 150 claims and that pharmacies wishing to reschedule must request within 7 days of the audit letter
• Section 5.9 states that Humana does not require pharmacies to break boxes of insulin pens and that pharmacies may submit max day supply on claims and monitor for future refill appropriateness (e.g. the PAAS “ILQ process”)
• FAQ #15 explains that audit results are typically sent within 30-60 days (PAAS often finds that Humana results take longer to receive than many other PBMs that often send results < 30 days)