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.

A grievance is an expression of dissatisfaction about 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 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:

• 10 calendar days for grievances related to disenrollment.
• 30 calendar days for all other grievances

If we need additional information to make a decision that is in your best interest or if you think we need more time to make a decision about a grievance, we can extend the grievance timeframe by 14 calendar days. We will notify you verbally or in writing of the extension.

An appeal is a request for us to reconsider an adverse decision we make or an adverse benefit determination. 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

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 30 days to process.

If waiting the 30 calendar-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 855-233-9868 (TTY: 711), Monday – Friday, 8 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

Additional reasons your appeal may be expedited;

• Your provider says the appeal needs to be faster
• You are asking for more of a service than you are getting right now;
• You are asking for home care services after you leave the hospital;
• You are asking for more inpatient substance abuse treatment at least 24 hours before you are discharged; or
• You are asking for mental health or substance abuse services that may be related to a court appearance

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 or the time for us to decide your appeal has expired, including any extensions.

How to File a Grievance or Appeal

To file a written appeal or grievance, write to:

Attn: Grievance and Appeals Department
P.O. Box 14359
Lexington, KY 40512-4359

Fax: 800-949-2961

To file an appeal or grievance by phone, call Member Services at 855-223-9868 TTY: 711.

To file an appeal online:

1. Go to  https://www.humana.com/denial or go to MyHumana and access the appeal form on the Documents and Forms page.
2. Complete the required fields:
   • Type the Humana member ID
   • Select the Date of birth using the drop-down arrows
   • Type the ZIP code
3. Review the Select complaint type page information and click the Show more information link for definition of an appeal.
4. Click the An appeal radio button.
5. Click the A medication or A medical service (or medical equipment) radio button base on the issue. Continue based on the selection:
   • If A medication and an appeal has been filed:
     1. Click the Yes radio button
     2. Click the Continue button

If the appeal has been submitted successfully, a Thank you message displays with the appeal response time frames specific to the your plan and Humana's Grievance and Appeal contact information.

To file a grievance online:

1. Go to https://www.humana.com/denial or go to MyHumana and access the grievance form on the Documents and Forms page.
2. Complete the required fields:
   • Type the Humana member ID
   • Select the Date of birth using the drop-down arrows
   • Type the ZIP code
3. Review the Select complaint type page information and click the Show more information link for definition of a grievance
4. Click the A grievance radio button
5. Click the checkbox for Which of the following describes your issue? You can select more than 1.
   • If a grievance has been filed:
     1. Click the Yes radio button
     2. Click the Continue button

If the grievance has been successfully submitted, a Thank you message displays with the grievance response time frames specific to the member's plan and Humana's Grievance and Appeal contact information.

You can file a complaint, also know as a grievance, about your SoonerSelect plan at any time with the Oklahoma Department of Insurance by calling 800-522-0071.