Grievances and appeals

An appeal is a request for us to reconsider a decision we make. For example:

• Your doctor may ask us for permission for you to have a certain procedure
• Our medical director reviews the request and decides that we cannot give permission (called an adverse benefit determination)
• We send this information to your provider and/or to you
• You and/or your provider disagree with our decision
• You and/or your provider file an appeal

You may file an appeal orally or in writing. An appeal may take up to 15 days to process.

Grievances

A grievance is a formal complaint or dispute expressing dissatisfaction with any aspect of the operations, activities, or behavior of Humana or its providers. For example:

• You call Customer Care and feel your wait time is longer than you want to wait
• You visit your doctor and are unsatisfied about an aspect of your visit
• You file a grievance with us to tell us about your experience

You may file a grievance orally or in writing. You can file a grievance at any time after the experience about which you are dissatisfied. A grievance may take up to 30 days to process.

You (member), a person you appoint, or your physician can submit a grievance or appeal request.

You can file a grievance or appeal our decision online, in writing, or by calling Customer Care at 800-787-3311 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time.

Online

Use our online form to file a grievance or appeal. When filling out the form, please provide as much information as possible.

You can use this form to:

• Submit a grievance about and tell us how you are dissatisfied with your experience
• File an appeal for a denied medical service, medical device, and/or prescription medication

After you file a grievance or appeal with our online form:

• You will get a confirmation email with details of your submission

You can get information about the status of any grievance or appeal you submit through our form by:

• Calling the number on the back of your member ID card to check the status of a grievance
• Using our online appeal tracker, opens new window to check the status of a medical appeal

In writing

If you submit a written request, please include the following:

• Your address, member ID, name, and telephone number
• Your service or claim number
• Your provider name
• The date of your service
• The reason you’re submitting the grievance or appeal and what you want to happen
• Any supporting documentation, like receipts for services, medical records, or a letter from your provider that you want to include

Send your completed grievance and appeal form to:

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

You also can fax the completed form to us at 800-949-2961.

You will get a letter within 5 business days after we get your grievance or appeal form, to let you know that we received the form.

To file a grievance or appeal with CMS:

• Call 800-MEDICARE (800-633-4227) (TTY: 877-486-2048)
• Complete and submit the Medicare Complaint Form

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

Call: 800-787-3311 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time

Fax: 855-336-6220

You or your doctor can request an expedited (fast) grievance when Humana has extended the time frame 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 time frames:

• Expedited (fast) appeal – Within 24 hours of receipt
• Standard appeal – Within 15 business days of receipt
• Expedited (fast) grievance – Within 24 hours of receipt
• Standard grievance – Within 30 days of receipt

If you need assistance, or for information on filing an aggregate number of grievances, appeals, and exceptions:

Call: 800-787-3311 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time

Fax: 855-336-6220

If you are filing a grievance or appeal on behalf of a member, you must submit a completed Appointment of Representative (AOR) Form or other type of representative form (e.g., power of attorney), along with the other information listed above.

Submitting an AOR Form tells us that you are authorized to work with us on the member’s behalf.

An AOR Form is active for 1 year from the date you and the members sign the form, unless revoked. Download, print, and complete an AOR Form. This form requires a handwritten signature.

Send your completed form to:

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

Fax your completed form to us at 800-336-6220.

You also can ask us to send you an AOR Form