Louisiana Medicaid: Grievances and appeals

Humana Healthy Horizons in Louisiana 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 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

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

• Submitting your grievance via the online form
• Calling Member Services at 1-800-448-3810 (TTY: 711)
• Filling out a request form
• Writing us a letter that includes:
  • Your first and last name, the Member number from the front of your Humana Member ID card, and your address and phone number in the letter, so we can contact you if we need to
  • Any information that helps explain your problem
• Mailing the form or letter to:
  
  Humana
  Grievance and Appeals Department
  P.O. Box 14546
  Lexington, KY 40512-4546
• Faxing the form or letter to 1-800-949-2961

We will send you a letter within five (5) 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 90 calendar days to let you know our decision. 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

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

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
• Calling Member Services at 1-800-448-3810 (TTY: 711)
• Filling out a request form
• Writing us a letter that includes:
  • Your first and last name, the Member number from the front of your Humana Member ID card, and your address and phone number in the letter, so we can contact you if we need to
  • Any information that helps explain your problem
• Mailing the form or letter to:
  
  Humana
  Grievance and Appeals Department
  P.O. Box 14546
  Lexington, KY 40512-4546
• Faxing the form or letter to 1-800-949-2961

We will send you a letter within five (5) business days from the receipt of your appeal request to let you know we received it.

After we complete the review of your appeal, we will send you a letter within 30 calendar days to let you know our decision. You or someone you choose to act for you may:

• Review all of 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, clinical records, other documents and records, and any new or additional evidence considered, relied upon, or generated by us, or at our direction, in connection with the appeal
  • This information shall be provided, upon request, free of charge and sufficiently in advance of the resolution timeframe

If you feel waiting for the 30-day timeframe to resolve an appeal could seriously harm your health, you can request that we make a decision faster: expedite the appeal. In order 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 72 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 do not change our decision or action because of your appeal:

• We will notify you of your right to request a state hearing
• You may only request a state hearing after you have gone through our appeal process

You have the right to ask for a state fair hearing from the Louisiana Department of Health after you complete the Humana Healthy Horizons in Louisiana appeal process. You must ask for a hearing within 120 days from the date on our appeal decision letter.

Submit your request for a state fair hearing online with the Division of Administrative Law (DAL

The DAL will make its decision within 90 days of receipt of your request.

Along with the online application, you must provide a copy of the notice we send you with our appeal decision. According to the DAL, you can:

• Upload a copy to the online request form
• Fax it to 225-219-9823
• Email it to LDHProcessing@adminlaw.state.la.us
• Mail it to:

Division of Administrative Law – Louisiana Department of Health Section
P.O. Box 4189
Baton Rouge, LA 70821

See your Member Handbook for more information about the state fair hearing process

If you are filing a grievance or appeal on behalf of a Humana Healthy Horizons in Louisiana member, 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

An AOR Form:

• Tells us that you the submitter is authorized to work with us on the member’s behalf
• Is active for 1 year from the date you and our member sign the form, unless revoked

Download, print, complete, and sign an AOR Form

Send your completed form to:

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

Fax your completed form to us at 1-800-949-2961.

See your Member Handbook for more information about the grievance and appeal process

Download the grievance and appeal request form