Ohio Medicaid: Grievances and appeals

As a Humana Healthy Horizons in Ohio member, you 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. For example:

• You call Member Services and feel your wait time is longer than you want to wait
• You visit your provider and are unsatisfied about an aspect of your visit

You may file a grievance in writing, online, or orally. You can file a grievance at any time after the experience about which you are dissatisfied.

We will respond to your grievance within the following time frames:

• 2 working days for grievances about not being able to get medical care
• 30 calendar days for all other grievances, except grievances about getting a bill for care you have received
• 60 calendar days for grievances about getting a bill for care you have received

If we need more time to make a decision about a grievance, we will send you a letter that explains:

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

If you think we need more time to make a decision about a grievance, you can ask us to take up to 14 calendar days.

You also have the right to file a grievance (complaint) at any time by contacting the:

Ohio Department of Medicaid
Bureau of Managed Care Compliance and Oversight
P.O. Box 182709
Columbus, OH 43218-2709
800-605-3040 or 800-324-8680

Ohio Department of Insurance
50 W. Town St.
3rd Floor – Suite 300
Columbus, OH 43215
800-686-1526

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

• We deny a claim that your provider sends us to pay for services you get
• We deny your provider’s request for you to have a certain procedure (called an adverse benefit determination)

If you and/or your provider disagree with our decision, you can file an appeal and ask us to reconsider.

You may file an appeal in writing, online, or orally within 60 calendar days from the date of our adverse benefit determination. An appeal may take up to 15 calendar days to process.

If waiting the 15-day time frame to resolve an appeal could seriously harm your health, you can ask us to expedite your appeal.

If you need us to expedite your appeal, you or your authorized representative can call us at 877-856-5702 (TTY: 711), Monday – Friday, 7 a.m. – 8 p.m., Eastern time.

For us to expedite your appeal, waiting could seriously jeopardize your:

• Ability to attain, maintain, or regain maximum function
• Physical or mental health
• Life

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 Ohio Department of Medicaid after you complete the Humana Healthy Horizons in Ohio appeal process. You must ask for a hearing within 90 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.

A state hearing is a meeting with you or someone you want to speak on your behalf, someone from the County Department of Job and Family Services, someone from Humana Healthy Horizons in Ohio, and a hearing officer from the Bureau of State Hearings within the Ohio Department of Job and Family Services (ODJFS).

In this meeting:

• You will explain why you think we did not make the right decision, and
• We will explain our reasons for making our decision

The hearing officer will listen and then decide who is right based on the rules and the information given.

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

Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings
P.O. Box 182825
Columbus, OH 43218-2825

Or by:

Email: bsh@jfs.ohio.gov
Call: 866-635-3748
Fax: 614-728-9574

For additional help, call the ODJFS Consumer Access Line at 866-635-3748.

If you want information on free legal services:

• Call your local legal aid office
• Call the Ohio State Legal Services Association at 800-589-5888

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

You can submit a grievance or appeal to us:

• Online
• By mail
• By fax

You also can start the grievance or appeal process by phone but will need to provide information to us in writing as well.

When you submit a grievance or appeal, please provide as much information as possible.

Online

Use our online 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

Use our online form to submit a grievance or file an appeal

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
• Using our online appeal tracker to check the status of a medical appeal

In writing

To file a grievance or appeal by mail or fax, please include the following information:

• 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)

To submit your grievance or appeal by mail, send the above information to:

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

To submit your grievance or appeal by fax, fax the above information to 800-949-2961.

We will send you a letter within 5 business days from the day we get your grievance or appeal form, to let you know that we received the information.

By phone

Call Member Services at 877-856-5702 (TTY: 711), Monday – Friday, 7 a.m. – 8 p.m., Eastern time. We will get some information from you and start the grievance or appeal process. You still must send an official request in writing by:

• Completing the online form, or
• Mailing the information to the address above, or
• Faxing the information to the fax number above

Filing on behalf of another member

If you are filing a grievance or appeal on behalf of a Humana Healthy Horizons in Ohio 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 authorized representative is a trusted person (e.g., family member, friend, provider, or attorney) that you appoint to speak on your behalf for purposes of the grievance or appeal process.

Submitting an AOR Form tells us that you are authorized to work with us on the member’s behalf.

An AOR Form is active for 1 year from the date you and our member sign the form, unless revoked. Download, print, and complete an AOR Form. This form requires a handwritten signature.

Send your completed form to:

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

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

Appointment of Representative Form, PDF

More on grievances and appeals

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

ODM Appeals Form, PDF