Be On the Lookout for Prescription Reversal Requests from Humana

Humana periodically performs retrospective claim reviews. If upon review Humana determines a claim was billed in error (i.e., after the Humana coverage was terminated), the pharmacy will get a prescription reversal letter. The reversal letter will include a claim detail report listing the claims and dates of service for member(s) who no longer had coverage with Humana at the time the claims were billed. Please see the PAAS Tips below for guidance on what steps to take if your pharmacy receives one of these prescription reversal requests.

PAAS Tips:

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  • Do NOT reverse the claim prior to performing an investigation
  • Make a good faith effort to call the patient and see if they have other insurance
    • If yes, try to rebill the claim with the insurance information provided by the patient
    • Only if the new claim is paid in full should the pharmacy reverse the original Humana claim and sign the form to send back to Humana
    • If the patient does not have other coverage for that date of service, or the pharmacy gets a rejection when trying to bill the new coverage, send a note to Humana per the guidance provided in the letter. You can also include a print screen of the rejection
  • Do not sign the claim detail report as Humana may interpret your signature as an approval to reverse the claim
  • Push back that the claim was adjudicated at the point of sale. If Humana would have had the coverage termination date populated correctly, the claim would’ve rejected at that time
  • Reiterate that you do NOT give Humana authorization to reverse the claim(s) in question
  • Write up a statement that the pharmacy made a good faith effort to contact the patient for additional coverage on that date(s) of service and the pharmacy should not be held liable for Humana’s error
Jennifer Ottman, CPhT