Grievances and appeals

If you have a grievance or appeal related to Humana Healthy Horizons in Kentucky or any aspect of your care, we want to hear about it and 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. A grievance does not involve decisions by Humana that are subject to an appeal, as outlined below. A grievance may take up to 30 days to process.

An adverse benefit determination is when you do not agree with a decision we make related to your benefits. If this happens, you can request an appeal. An appeal is a request for us to reconsider our decision. You must file an appeal within 60 days of the adverse benefit determination. An appeal may take up to 30 days to process.

If you need us to expedite the grievance or appeal process, call us at 800-444-9137 (TTY: 711).

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 your complaint 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
• Use our online appeal tracker to check the status of a medical appeal

In writing

To file a grievance or appeal, you can submit a grievance or appeal form to tell us what happened. Please provide as much information as you can so we can help resolve your issue. When filling out your form, you’ll need to provide:

• 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
• A completed Appointment of Representative Form, if filing on behalf of a member (see below section for more information)

Send your completed grievance and appeal form to:

Humana Healthy Horizons in Kentucky
Grievance and Appeal Department
P.O. Box 14546
Lexington, KY 40512-4546
Attn: Grievance and Appeal 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 it.

By phone

Call Enrollee Services at 800-444-9137 (TTY: 711), Monday – Friday, from 7 a.m. – 7 p.m., Eastern time. We will get some information from you and start the appeal process. You still must send an official request for appeal to us in writing by:

• Completing a grievance or appeal form
• Sending the completed form to the address above

If you are filing a grievance or appeal on behalf of a Humana Healthy Horizons in Kentucky enrollee, 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 enrollee’s behalf.

An AOR Form is active for 1 year from the date you and the enrollee sign the form, unless revoked. Download, print, and complete an AOR Form, which you can find on the Document and Forms page. This form requires a handwritten signature.

Send your completed form to:

Humana Healthy Horizons in Kentucky
P.O. Box 14546
Lexington, KY 40512-4546
Attn: Grievance and Appeal Department

Fax your completed form to us at 800-949-2961.

State fair hearing

You have the right to ask for a state fair hearing from the Department for Medicaid Services, after you complete the Humana appeal process. You must ask for a hearing within 120 days from the date on our appeal decision letter. You must send your request for a state fair hearing in writing, by mail or fax, with a signature.

To request a state fair hearing, send your completed request to:

Office of the Ombudsman and Administrative Review
Attn: Medicaid Appeals and Reconsiderations
275 E. Main St., 2E-O
Frankfort, KY 40621

Phone: 502-564-5497
Fax: 502-564-9523

You can learn more about the grievance and appeal process in your Enrollee Handbook.