As a Humana Healthy Horizons in Illinois member, you can appeal a decision that we make about your healthcare or share a grievance you have with any aspect of your healthcare. We want to hear about this from you and see how we can help.

What are grievances and appeals? 

We want you to be happy with the care you get from Humana Healthy Horizons in Illinois. We hope you get the best care possible.

If you are not happy with any part of your health care plan, customer care, your doctor, or a facility, you can send in a grievance. You can also appeal a claim or a denied service.

To file a grievance or appeal, you will need: 

• Your name, member ID, telephone number and address
• Your service or claim number
• Your provider’s name
• The date of your service
• The reason you're submitting the appeal or complaint 
• An explanation of 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

You will get a letter from us within 48 hours after we receive your appeal or complaint.

Filing for another member

If you are filing an appeal or grievance on behalf of a member other than yourself, you need an Appointment of Representative (AOR) form on file with Humana. This form lets us know that you are authorized to work with Humana on the member’s behalf. 

You also may use other appropriate legal documentation that shows your authorized representative status (such as power of attorney)

AOR forms are active for one year from the date the form is signed by both the member and the representative, unless revoked.

Download, print, and complete the AOR form, found on the Document and Forms page; sign the form; and return it to us.

Appointment of Representative form – English/Spanish pdf opens in new window

Send your completed form to: 

Humana Healthy Horizons in Illinois
P.O. Box 14163
Lexington, KY 40512-4163
Attn: Grievance & Appeals Department

External Review by Independent Review Organization

If you do not agree with the appeal decision, you may also request an External Review by an Independent Review Organization (IRO). You or your authorized representative must request the IRO review in writing within 30 calendar days of the date on your appeal decision letter. The IRO will be conducted at no cost to you. Requesting an external review does not limit your ability to request a State  fair hearing. You can request review by an IRO and a State fair hearing at the same time. 

The IRO will decide your appeal within 45 days for a standard appeal, or within 72 hours for an expedited appeal The decision by the IRO is binding, meaning Humana will follow their decision. To request the External Review by an Independent Review Organization, reach out to Humana in writing at: 

Humana
Grievance and Appeals Department
P.O. Box 14163
Lexington, KY 40512- 4163

Information to include when requesting an External Review:

• Name
• Health Choice ID number
• Phone number where you can be reached
• Reason for your appeal
• Any information you feel is important to your appeal request (examples include documents, medical records, or provider letters)

State Fair Hearing

Once a decision is made on your appeal, a Notice of Appeal Resolution letter will be sent to you. This letter will tell you the reason for the decision. If you feel the decision is not correct, you may request a State fair hearing. You can write a letter telling the State why you think the appeal decision is wrong. Please make sure to also include your name and other important information, like the dates of the decision, which is on the letter. Send your appeal to:

You can request a fair hearing related to medical services or items, or Elderly Waiver Community Care Program (CCP) verbally or in writing using the following:

• By mail:
  Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings
  69 W Washington Street, 4th Floor
  Chicago, IL 60602
• Email: HFS.FairHearing@illinois.gov
• Fax: (312) 793-2005
• Phone: (855) 418-4421 TTY: (800) 526-5812

You can request a fair hearing related to mental health services or items, substance abuse services, Persons with Disabilities Waiver services, Traumatic Brain Injury Waiver services, HIV/AIDS Waiver services, or any Home Services Program (HSP) service verbally or in writing using the following:

• By mail:
  Illinois Department of Human Services Bureau of Hearings
  69 W Washington Street, 4th Floor
  Chicago, IL 60602
• Email: DHS.BAH@illinois.gov
• Fax: (312) 793-3387
• Phone: (800) 435-0774, TTY: (877) 734-7429 
• Online at: https://abe.illinois.gov/abe/access/appeal opens in new window

If you file a State fair hearing request, you must do it within 120 calendar days after the date on the denial letter. If your appeal is about a service, you are still using, like in-home healthcare, you will get at least 10 days notice before your service is stopped.

At your State fair hearing, you can speak for yourself or have help, or representation, from legal counsel, a friend, relative, or someone you trust to speak for you. You will be shown your entire medical case file. You will be shown all materials used by FSSA, your county office, the provider or Humana that relate to your appeal and were used to make the original decision.

Questions? 

You can find more information about grievances and appeals in your Member Handbook .

If you need an expedited appeal or grievance process, call us at 800-787-3311 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time.