Appeals

An appeal is a request for us to reconsider a decision we make. 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 do not agree with our decision
5. You and/or your provider file an appeal

You or your authorized representative can file an appeal  by phone or in writing within 65 calendar days from the date of our first decision. It may take up to 30 days for us to review your appeal and give you an answer.

If waiting the 30 days for a decision could harm your health, you or your authorized representative can ask us to make a decision faster, or expedite your appeal.

We will do this if waiting could seriously harm your:

• Life,
• Physical or mental health; or
• Ability to reach, keep, or get back your best level of health and strength 

We make decisions on expedited appeals within 48 hours, or even sooner if your health needs it.

If we need more time to make a decision about an appeal, we will try to provide quick notice by phone that more time is needed. We will also send you a letter that explains:

• That we need to take up to 14 more calendar days
• Why we need more time

You can give us more information to help with your appeal (such as medical records, supporting statements from a provider, etc.) over the phone, in person, or in writing. You can include the information with your appeal request or submit it at any time during the appeal process. For a standard appeal, we have to receive this information within 30 calendar days of us receiving your appeal request. For an expedited appeal, we must receive any supporting information within 48 hours of your appeal request.

At any time during the appeal or state fair hearing process, you or your authorized representative can request copies of your appeal file, at no cost, by contacting Member Services.

No one will get in trouble or be treated badly because:

• A member or provider files an appeal
• A provider asks for an appeal for a member, with the member’s written permission

For appeals involving Medicaid benefits, you and your authorized representative have the right to ask for a Medicaid State Fair Hearing after you complete the Humana appeal process. A state fair hearing must be requested within 120 days from the date on the appeal decision letter.  You also have the right to ask for a state fair hearing if Humana does not give you a decision about your appeal within 30 days for a standard appeal or 48 hours for an expedited appeal.

You can ask for an Indiana State Fair Hearing by contacting the Indiana Office of Administrative Law Proceedings (OALP). You must request a hearing in writing. While correspondence can be mailed, faxed, or emailed, email is preferred.

Family and Social Services Administration
Office of Administrative Law Proceedings - FSSA Hearings
100 N. Senate Avenue, Room N802
Indianapolis, IN 46204
Fax: (317) 232-4412
Email: fssa.appeals@oalp.in.gov

Your written request for a Medicaid state fair hearing must include the following information:

• Your name
• Your member number
• Your Medicaid ID number
• A phone number where we can reach you or your authorized representative

In Indiana you can also ask for an Indiana External Review if you do not agree with Humana’s appeal decision. An external review is completed by an Independent Review Organization (IRO) that is not connected to Humana. The IRO will review your case and make a decision about your appeal.

An external review is available for denied services, denials for medical necessity, and denials for services that are considered experimental or investigational. You have 120 days from the date of Humana's appeal decision letter to request an external review. The state fair hearing process can run at the same time as an external review.

Ask for an Indiana External Review by submitting your request to Humana in writing at:

Grievance and Appeal Department
P.O. Box 14163
Lexington, KY 40512-4163
Fax # 1-888-599-2730

Please include your name, address, phone number, reference number, and reasons for the external review request. The reference number can be found at the top of the appeal denial letter.

A grievance is a formal way to tell us when you are unhappy with something about Humana or our providers. For example, you might file a grievance if:

• You call Customer Care and feel your wait time is longer than you want to wait
• You visit your doctor and are  unhappy about a part of your visit

If this happens , you can contact Humana and file a grievance to let us know about your experience.

You or your authorized representative can file a grievance by phone or in writing by contacting Humana. You can file a grievance at any time after the experience that you are unhappy about. It may take up to 30 days for us to review your grievance.

You can ask us to make a faster decision about your grievance if:

• You do not agree with us taking more time to decide about your authorization request or appeal.
• We deny your request for a faster appeal.

If we need more time to make a decision about a grievance, we will attempt to provide quick notice by phone that more time is needed. We will also send you a letter that explains:

• That we need to take up to 14 more calendar days
• Why we need more time