Oklahoma SoonerSelect: Grievances and Appeals

Humana Healthy Horizons in Oklahoma 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.

Grievances

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.

To let us know about your grievance, you can:

• Call member services at 866-274-5888 Monday – Friday, 8 a.m. – 8 p.m. Eastern time.
• Submit your grievance via the online form opens in new window .
• Write 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.

• Fill out grievance/appeal request form pdf opens in new window .
  
• Fill out grievance/appeal request form - Spanish pdf opens in new window .
• Fax your grievance to 800-949-2961.
• Mail the form or letter to:

Humana
Grievance and Appeals Department
P.O. Box 14163
Lexington, KY 40512-4163.

We will send you a letter within 10 calendar days after we get your grievance to let you know we have it. We will review your grievance within 30 calendar days. After we make a decision, we will send you another letter within 3 calendar days to tell you what we decided. 

Sometimes Humana needs more facts to make a decision. If that happens, and OHCA is satisfied, upon request, Humana may take 14 more calendar days. This extra time must be in your favor. You may also ask for 14 more calendar days.

If Humana takes more time, we will try to tell you right away. You will receive a phone call from us telling you that we need more time. We will also send a letter in 2 calendar days. The letter will explain why we need more time.

You can file a grievance if you do not agree with that choice.

If your grievance is about a health crisis, you should ask for a fast (expedited) review. An expedited review takes 48 hours after we get your grievance.

Negative actions will not be taken against:

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

Appeals

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 at Humana.com .

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 opens in new window
  
• 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.
• Filling out grievance/appeal request form pdf opens in new window  
  
• Filling out grievance/appeal request form - Spanish pdf opens in new window .
• Faxing your appeal to 800-949-2961
• Mailing the form or letter to:

Humana
Grievance and Appeals Department
P.O. Box 14163
Lexington, KY 40512-4163.

We will send you a letter within 5 calendar days after we get your appeal to let you know we have it. We will review your appeal within 30 calendar days. After we make a decision, we will send you another letter within 3 calendar days to tell you what we decided. 

Humana may need more time to look at your appeal if it will benefit you. If so, Humana can ask for 14 more calendar days to finish the review. Humana must show there is a good reason to need more time, and OHCA must agree. If more time is needed, Humana can ask in writing for another 14 calendar days. You can also ask for this extra 14 calendar days. 

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, or ordered by an authorized provider. Also, the original time period for those services must not have expired. We will continue services if you request an appeal within 60 calendar days from our Notice of Adverse Benefit Determination letter. Your benefits will continue until one of the following occurs:

• 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 will not be required to pay for these services.

After you submit your appeal

After we complete the review of your appeal, we will send you a letter within 3 calendar 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 calendar 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 criteria for an expedited appeal. We will only grant an expedited appeal if 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 calendar day timeframe and give you written notice of the reason for the decision within 2 calendar days. You have the right to file a grievance if you disagree with that decision. 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 calendar 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.

External Review by Independent Review Organization

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 calendar 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 14163
Lexington, KY 40512-4163.

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)

State fair hearing

Once Humana makes a decision 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 are on the letter. Send your appeal to:

Mail: 

Oklahoma Health Care Authority
Grievance Docket Clerk
P.O Drawer 18497
Oklahoma City, OK 73154-0497

Fax: 405-530-3444

Email: docketclerk@okhca.org

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 calendar day’s 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.

Visit the Oklahoma SoonerCare member website to learn more opens in new window .