Humana Dual Fully Integrated in Illinois: Grievances and appeals

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Your appeal and grievance rights

As a Humana Dual Fully Integrated (HMO D-SNP) member in Illinois, you can appeal a decision that we made about your healthcare or share a grievance you have with any aspect of your healthcare. We want to help.

What are grievances and appeals?

We want you to be happy with the care you get from Humana. 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 file a grievance. You can also appeal a claim or a denied service.

Appeals

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

  1. Your doctor may ask us for permission for you to have a procedure
  2. Our medical director reviews the request and decides that we can’t give permission. This is called an Adverse Benefit Determination.
  3. We send this information to your provider and/or to you
  4. You and/or your provider disagree with our decision
  5. You and/or your provider file an appeal

You must file an appeal orally or in writing within 65 calendar days from the date of our decision. An appeal may take up to 30 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.

In these situations, you would file a grievance with us to tell us about your experience.

You can 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. 

How to file a grievance or appeal

Online

You can use our online form opens in new window 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 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 using our online form, you will get a confirmation e-mail with details of your submission.

In writing

To file a grievance or appeal, you can submit a Grievance/Appeal Request Form to tell us what happened. Please provide as much information as you can so we can help resolve your issue.

Download and return to us the completed form:

Grievance/Appeal Request Form – English pdf opens in new window

Grievance/Appeal Request Form – Spanish pdf opens in new window

Send your completed Grievance/Appeal Request Form to:

Humana Dual Fully Integrated (HMO D-SNP) in Illinois
Attn: Grievances and Appeals
P.O. Box 14163
Lexington, KY 40512-4163

By phone

You can also submit grievances and appeals by phone. Call Customer Care at 800-787-3311 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time.

What information will I need?

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

We will send you a letter within five business days after we receive your appeal or complaint to let you know we received it.

Checking on the status of a grievance or appeal

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

  • Call the number on the back of your member ID card to check the status of a grievance.
  • Use our online appeal tracker to check the status of a medical appeal

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, sign the form; and return it to us.

Find the AOR form pdf opens in new window

Send your completed form to:

Humana Dual Fully Integrated (HMO D-SNP) in Illinois
Attn: Grievances & Appeals
P.O. Box 14163
Lexington, KY 40512-4163

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:

866-274-9834 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Central time. 

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