Humana Gold Plus Integrated (Medicare-Medicaid Plan) Medicare-Medicaid Plan (MMP) - (Appeal and Grievance)

What is a grievance?

A grievance is any complaint or dispute (other than an organization determination) that expresses dissatisfaction. This could be with any of the operations, activities, or behavior of a Medicare or Medicaid health plan, or its providers.

What is an appeal?

An appeal is a formal way of asking us to review our initial decision. For example, we might decide that a service, item or drug you want is not covered, or that Medicare or Medicaid does not cover it. If you or your doctor disagrees with our decision, you can appeal.

Who can submit a grievance or appeal request?

You (member), a person you appoint, or your physician. Refer to the How to Appoint a Representative section for additional information.

How can I submit the grievance or appeal request?

You can file a grievance or appeal our decision in writing or by calling Customer Care. If you submit a written request, please include the following:

  • Member’s Name
  • Member’s ID Number
  • Member’s Phone Number
  • Member’s Address
  • Date of Service or Claim(s) Numbers (if applicable)
  • Provider’s Name (if applicable)
  • Explain the details of your grievance or appeal and provide your expected outcome

Mailing Address:

Humana Inc. Attn: Grievances and Appeals P.O. Box 14546 Lexington, KY 40512-4546

Call Customer Care: 1-800-787-3311 (TTY: 711)

Can I request an expedited 'fast' appeal?

You or your doctor can request a fast appeal for situations in which the standard resolution timeframe could seriously jeopardize your life, health, or ability to regain maximum function.

Call Customer Care: 1-800-787-3311 (TTY: 711)

Fax Number: 1-855-336-6220

When can I request an expedited 'fast' grievance?

You or your doctor can request an expedited 'fast' grievance when Humana has extended the timeframe of an appeal or denies a request for an expedited 'fast' appeal.

Be sure to submit all supporting documentation, along with your grievance or appeal request. After we receive the request, we will make a decision and send written notice within the following timeframes:

  • Expedited Appeal – Within 24 hours of receipt
  • Standard Appeal – Within 15 business days of receipt
  • Expedited Grievance – Within 24 hours of receipt
  • Standard Grievance – Within 30 days of receipt

If you need assistance, call Customer Service toll free at 1-800-787-3311 or by sending a fax to 1-855-336-6220. If you have a speech or hearing impairment and use a TTY, call 711. Our hours are 8 a.m. to 8 p.m. (CST) Monday through Friday.

Our automated phone system may answer your call after hours, during weekends and holidays. Please leave your name and telephone number, and we will call you back by the end of the next business day.

Visit Humana.com for 24 hour access to information like claims history, eligibility, and Humana’s drug list. You can also use the physician finder and get health news and information.

If you would like information on how to obtain an aggregate number of grievances, appeal, and exceptions filed with us please contact Customer Service at 1-800-787-3311 (TTY:711).

How to Appoint a Representative

Humana Gold Plus Integrated MMP Grievance and Appeal Requests: If the grievance or appeal request comes from anyone other than you (the member), we must have authorization from you before we can review the grievance or appeal.

You can appoint anyone to act on your behalf by sending us an Appointment of Representative Form. You and your representative must sign the form for it to be valid.

A representative who is appointed by the court or who is acting under state law can also file a request for you after sending us the legal representative form. You do not need to complete an Appointment of Representative Form if you send another legal representation document with your request.

Appointment of Representative: You can get a form by calling Customer Service toll free at 1-800-787-3311. If you have a speech or hearing impairment and use a TTY, call 711. Or, you can download the form from the link below:

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS1696.pdf (link opens in new window) 

How do I submit the form? You can submit the form via fax or mail.

Fax Number: 1-855-336-6220

Mailing Address:

Humana Inc. Attn: Grievances and Appeals P.O. Box 14546 Lexington, KY 40512-4546

Refer to your Member’s Handbook for more information about the grievance and appeal processes.