Humana Offers Real Time Claim Adjudication

A Humana healthcare provider billing a patient for services at the point of service.

This capability allows a provider to bill for services at the “point of service.” A fully adjudicated response is returned from Humana, detailing the total charge submitted and allowable charges, as well as the patient’s responsibility.

Humana’s real-time claims adjudication affords providers the ability to bill for services and collect accurate patient liabilities (coinsurance, deductible, and copayment) at the point of service.

Industry Dilemma

Providers across the country are increasingly concerned about the impact consumer-directed health care plans and high-deductible health plans have on their ability to collect timely payment from their patients. These plans require patients to pay more out-of-pocket costs. Most payers are asking providers not to collect at the time of service. Any attempt to collect at the time of service may create credit balances or patient dissatisfaction. Providers believe it will get increasingly difficult to get payment from patients.

What is Real Time Claims Adjudication (RTCA)?

RTCA enables a provider to bill for service before the patient leaves the office and to receive a fully adjudicated response back – at the time of service. With this technology, a provider can print out the response, displaying total, and allowable charges, as well as the patient’s responsibility (coinsurance, deductible, and copayment). Providers can be certain of the amount the patient should pay at the time of service.

Humana and RTCA

Humana has the ability today to adjudicate claims in “real time” for some of our health plans. (Members on these plans have been assigned unique member identifiers (UMIDs) that consist of nine digits followed by a two-digit suffix. The UMID for these members usually begins with zeros. (Example: 000123456-01). The member’s UMID is displayed on the member’s Humana ID card.

This technology is advantageous to all parties involved in the health care industry – especially providers concerned about the potential for bad debt. RTCA provides immediate payment calculations on claims, reducing bad debt concerns and cutting administrative hassles by avoiding the need to estimate claims payment. However, there is one concern. Most provider offices are not quite ready to handle this new technology.

Why Aren’t Providers Ready?

Even though providers are anxious to speed up their payment processes, many of their offices are not yet ready to perform RTCA today. Providers have been able to submit “real time” professional claims to Humana via, but they have to manually key them into an entry screen. Most providers are unwilling to do this duplicate keying. Unfortunately, many providers are unable to take advantage of RTCA for a number of reasons.

  • Many providers are not able to have bills ready for submission for at least 2 days.
  • Many providers’ practice management systems are unable to submit claims in “real time.”
  • Most clearinghouses are unable to transmit provider claims in “real time.”

What is Humana’s Solution to the Dilemma?

The Humana solution is to create interoperability between provider, practice management vendor, clearinghouse, and payer. Humana has been working with a number of practice management systems and clearinghouses, including ZirMed and Availity, to create “real time” connectivity. Through these partnerships, Humana has successfully developed an integrated real-time claim adjudication solution. To learn more about this capability or to determine if your practice is a candidate for this technology, please contact

Up-Coming Webinars

Learn how to get your claims fully adjudicated in less than a minute and collect the patient’s share at the time of service.