Procedures for filing an organization/coverage determination

What is a coverage decision?

A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services, items, or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.

If you or your doctor are not sure if a service, item, or drug is covered by Medicare or Medicaid, either of you can ask for a coverage decision before the doctor gives the service, item, or drug.

How to ask for a coverage decision to get a medical, behavioral health or long-term care service

To ask for a coverage decision, you can call, write, fax us, or ask your representative or doctor to ask us for a decision. It usually takes up to 14 calendar days after you asked for us to give you a decision. If we don’t give you our decision within 14 calendar days, you can appeal. To get a coverage decision: You can call us at: 1-855-280-4002 TTY: 711.

We’re available Monday – Friday, from 8 a.m. – 8 p.m. Eastern Time. Our automated phone system may answer your call after hours, during weekends, and holidays. You can leave your name and telephone number, and we’ll call you back by the end of the next business day. You can to write us at: Humana P.O. Box 14168, Lexington, KY 40512-4168

How to ask for a fast coverage decision

The legal term for “fast coverage decision” is “expedited determination.” If we approve the request, we will notify you of our decision within 72 hours.

You can get a fast coverage decision only if you are asking for coverage for medical care or an item you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care or an item you have already received.)

You can get a fast coverage decision only if the standard 14 day deadline could cause serious harm to your health or hurt your ability to function.

If your doctor says that you need a fast coverage decision, we will automatically give you one. If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision.

To get a fast coverage decision: You can call us at: 1-855-280-4002 TTY: 711 or fax us at: 1-800-266-3022.

Sometimes we need more time to give you a decision. When this happens, we will send you a letter telling you that we need to take up to 14 more days. If you disagree with waiting the extra time, the letter will tell you how to appeal.

Who can I call for help asking for coverage decisions?

You can ask any of these people for help:

Call Humana Customer Care at 1-855-280-4002 (TTY: 711).

Call the Office of the State Long-Term Care Ombudsman for free help. The Office of the State Long-Term Care Ombudsman helps people receiving long-term care services. The phone number is 1-800-552-3402.

Call the Virginia Insurance Counseling and Assistance Program (VICAP) for free help. The VICAP is an independent organization. It is not connected with this plan. The phone number is 1-800-552-3402.

Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision.

Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your “representative” to ask for a coverage decision.

If you want a friend, relative, or other person to be your representative, call Customer Care and ask for the “Appointment of Representative” form. You can also get the form on the Medicare website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf or on our website at https://www.humana.com/individual-and-family-support/tools/member-forms. The form will give the person permission to act for you. You must give us a copy of the signed form.

You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form. However, you do not have to have a lawyer to ask for any kind of coverage decision.