Humana PathWays members can:

• Share a grievance you have with any aspect of your healthcare
• Appeal a decision that we make about your healthcare

After we hear from you, we will see how we can help.

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

• You call Member Services for assistance, and you feel your wait time is longer than you want to wait
• You visit your doctor and are not satisfied with some aspect of your visit

You can let us know about your grievance by doing one of the following:

• Call member services at 866-274-5888 Monday – Friday, 8 a.m. – 8 p.m. Eastern time
• Submitting your grievance via the online form
• Writing us a letter
  • Be sure to put your first and last name, the Medicaid ID number from the front of your Humana Member ID card, and your address and phone number in the letter. This will allow us to contact you if we need to. You should also send any information that helps explain your problem.
• Faxing your grievance to 800-949-2961
• Mailing the form or letter to:
  
  Humana
  Grievance and Appeals Department
  P.O. Box 14169
  Lexington, KY 40512-4169

We will send you a letter within three (3) business days from the day we receive your grievance to let you know we received it.

We will then review it and send you a letter within 30 calendar days to let you know our decision. If necessary, we may request in writing an additional 14 calendar days beyond if resolution requires additional time. You may also request this 14 day extension. If your grievance is a result of a health crisis, please request an expedited (faster) review. Expedited grievances will be reviewed within 48 hours of receipt.

Negative actions will not be taken against:

• A Member who files a grievance
• A provider that supports a member’s grievance or files a grievance on behalf of a member, with written consent

If you have questions or concerns about an adverse benefit determination, you can file an appeal with Humana. You can file an appeal in writing, by calling member services, or by completing your appeal online.

If you are unhappy with a benefit denial or action we take, you or your authorized representative can file an appeal. An appeal is asking for a review because you do not agree with a decision the State, or Humana has made. You have the right to file an appeal if you disagree with the decision. You do not have to pay to file an appeal. You can also appeal if Medicaid or Humana stop providing or paying for all or part of a health care service, supply, or prescription drug you think you still need.

You must file your appeal within 60 calendar days from the date on the denial letter which is called the Notice of Adverse Benefit Determination. You can file by calling or writing to us.

If needed, we can help you file an appeal. You can also get help from others. People who can help you are:

• Someone you choose to act for you, with your written consent
• Your legal guardian
• A provider you choose to act for you, with your written consent
• Interpreters that we will provide to you, if needed

You can file an appeal by:

• Submitting your appeal via the online form
• Writing us a letter
  • Be sure to put your first and last name, the Member number from the front of your Humana ID card, and your address and phone number in the letter. This will allow us to contact you if we need to. You should also send any information that helps explain your appeal.
• Faxing your appeal to 800-949-2961
• Mailing the form or letter to:
  
  Humana
  Grievance and Appeals Department
  P.O. Box 14169
  Lexington, KY 40512-4169

We will send you a letter within three (3) business days from the receipt of your appeal request to let you know we received it.

Continuation of Benefits during the Appeal Process

For some service denials, you may request to continue services during the appeal and State Fair Hearing process. Services that can be continued must be services that you are already receiving, including services that are being reduced or terminated. Also, the original time period for those services must not have expired. We will continue services if you request an appeal within ten (10) days from our Notice of Adverse Benefit Determination letter, or before the date we told you the services would be reduced or terminated, whichever is later. Your benefits will continue until one of the following occurs:

• Until the original authorization period for your services has ended
• The member does not request a State fair hearing and continuation of benefits within ten (10) calendar days from the date the Contractor sends the notice of an adverse appeal resolution
• You withdraw your appeal
• Following a State Fair Hearing, if the Administrative Law Judge issues a decision that is not in your favor

If the Administrative Law Judge agrees with Humana’s first decision to deny your service, then you may be required to pay for these services.

After we complete the review of your appeal, we will send you a letter within 5 business days of resolution to let you know our decision. You or someone you choose to act for you may:

• Review all the information used to make the decision
• Provide more information throughout the appeal review process
• Examine the Member’s case file before and during the appeals process
  • This includes medical records, other documents, and any new or additional evidence considered, relied upon, or generated by us, or at our direction, in connection with the appeal

This information will be provided free of charge and sufficiently in advance of the resolution timeframe.

If we extend the timeframe for your appeal or decide expedited criteria is not met we will make reasonable efforts to give you prompt oral notice of the delay, and give you written notice of the reason for the decision to extend the timeframe within two (2) calendar days.

If you feel waiting for the 30-day timeframe to resolve an appeal could seriously harm your health, you can request that we decide faster and expedite the appeal. For your appeal to be expedited, it must meet the following criteria:

• A delay could seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function.

We make decisions on expedited appeals within 48 hours, or as fast as needed based on your health. Negative actions will not be taken against:

• A Member or provider who files an appeal
• A provider that supports a member’s appeal or files an appeal on behalf of a member, with written consent

If we decide expedited criteria is not met, we will transfer the appeal to the standard 30 day timeframe and give you written notice of the reason for the decision within two (2) calendar days. If we need to extend the timeframe for a standard appeal, we will:

• Write you and tell you what information is needed. For expedited appeals, we will call you right away and send a written notice later.
• Explain why the delay is in your best interest.
• Make a decision no later than 14 days from the 30-calendar day standard timeframe.

You can present, in person or in writing, evidence (such as medical records, supporting statements from a provider, etc.) to include with your appeal submission prior to the end of the appeal resolution timeframe. For a standard appeal, we must receive this information within 30 calendar days of us receiving your appeal. For an expedited appeal, we must receive any supporting information within 48 hours of receipt of the appeal.

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 120 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 15 business 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 14169
Lexington, KY 40512-4169

Information to include when requesting an External Review:

• Name
• Medicaid 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)

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:

Mail: Office of Administrative Law Proceedings – FSSA Hearings
402 W. Washington St., Rm E034
Indianapolis, IN 46204

Fax: 317-232-4412

Email: fssa.appeals@oalp.in.gov

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.