Humana Healthy Horizons® in Louisiana offers an external medical review to a provider who is unsatisfied with the Humana Healthy Horizons decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity. Services that are denied for reasons other than lack of medical necessity are not subject to external medical review.
Humana Healthy Horizons uses the following criteria to determine medical necessity:
These guidelines are intended to allow Humana Healthy Horizons to provide all members with care that is consistent with national quality standards and evidence-based guidelines. These guidelines are not intended as a replacement for a physician’s medical expertise; they are to provide guidance to our physician providers related to medically appropriate care and treatment.
The external medical review process:
A provider must submit a request for an external medical review within 30 calendar days of receiving the Humana Healthy Horizons decision.
You can file an external medical review verbally or in writing. To file an external medical review:
Send this written information to:
Humana Healthy Horizons in Louisiana
Grievance and Appeal Department
P.O. Box 14546
Lexington, KY 40512-4546
Or fax this written information to 1-800-949-2961.
Following the external medical review, a letter is sent within:
The external medical review decision is final and binding. If the external medical review determination is reversed, Humana Healthy Horizons will authorize the services within 72 hours or pay for the disputed service within the time frames established for claims payment.
See the Humana Healthy Horizons in Louisiana Provider Manual for other information about the grievances and appeals process.