Wiki Humana denying claims for "no referral" even though we attached it

Create Wiki
C

CatchTheWind

Guest
Messages
649
Location
Boca Raton, FL
Best answers
0
We are constantly getting denials from Humana with reasons N630 and CO 243 ("referral not authorized by attending physician" and "Services not authorized by network/primary care providers"). This is in spite of having a referral which the PCP documented on the Humana website and we attached the number to the claim.

Has anyone else had this problem, and what have you done about it?
 
Hi, our office have been dealing with the same issue, we call Humana and they deny all Labs due to ("referral not authorized by attending physician" and "Services not authorized by network/primary care providers", however, when we call they are able to see we are the PCP and no auth is needed. All they do is send the claims back but still comes back denied for the same reason.
 
Our practice is experiencing a similar issue with surgical claims submitted with any type of closure. They pay on the excision or MOHS but deny closures for no authorization when we clearly have an authorization number on the claim. We contact Humana and they just send the claim back and we’ve been paid and pretty quickly, It must be an internal issue they are aware of.
 
CatchTheWind said:
We are constantly getting denials from Humana with reasons N630 and CO 243 ("referral not authorized by attending physician" and "Services not authorized by network/primary care providers"). This is in spite of having a referral which the PCP documented on the Humana website and we attached the number to the claim.

Has anyone else had this problem, and what have you done about it?
Click to expand...
 
We have recently experienced the same issue now and been instructed by our provider representative to send the claims to Humana concierge and they review the issue and have reprocessed them.
 
Our office is experiencing denials for no referral also. Not to mention the slow reimbursement for MX Hawaii for Humana claims. It over 60 days or more to get paid. Is anyone getting paid faster?
 
We have been speaking to someone at Humana who suggests that part of the problem is that the referring provider is putting the wrong "service type" on the referral. For codes from the medical section of CPT they must put "evaluation and treatment" (AKA "consultation and treatment") as the service type, and for any codes from the surgical sections they have to use "outpatient surgery."

He also suggested that we NOT put the referral number on the claim, because if the patient has multiple referrals, Humana's system may want to attach it to a different one than the one we've attached, and this will cause a denial.

Finally, he said that if the PCP has to make a change in a referral, they must do it via phone or fax. If they use the online system, it won't get through to them (although they are working on fixing this.)
 
We were informed by the Humana Concierge unit that this is a known issue and claims projects are in place to reprocess and pay and a target date in September to have this issue corrected.
 
We have indeed had better success getting claims paid when we ensure that the PCP uses the correct TOS (type of service): "medical" for CPT codes starting with 9, and "surgical" for codes starting with other numbers.
 
You must log in or register to reply here.
Top