South Carolina D-SNP: Grievances and appeals

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 Customer Care and feel your wait time is longer than you want to wait
• You visit your doctor and are unhappy about part of your visit

In these situations, you would file a grievance with us to tell us about your experience.

You or your authorized representative can file a grievance orally or in writing by contacting Humana. You can file a grievance at any time after the experience that you are unhappy about. A grievance may take up to 30 days to process.

You can ask us to make a decision faster or expedite your grievance if:

• You disagree with our decision to extend the timeframe for your authorization request or appeal
• We deny your request for an expedited appeal

If we need more time to make a decision about a grievance, we will attempt to provide prompt oral notice that more time is needed. We will also send you a letter that explains:

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

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

1. Your doctor may ask us for permission for you to have a procedure
2. Our medical director reviews the request and decides that we can’t give permission. This is called an adverse benefit determination
3. We send this information to your provider and/or to you
4. You and/or your provider disagree with our decision
5. You and/or your provider file an appeal

You or your authorized representative can file an appeal orally or in writing within 65 calendar days from the date of our initial decision. A standard appeal may take up to 30 days to process.

If waiting the 14-day time period to resolve your appeal could seriously harm your health, you or your authorized representative can ask us to make a decision faster or expedite your appeal.

We will expedite your appeal if waiting the standard time period could seriously jeopardize your:

• Life,
• Physical or mental 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.

If we need more time to make a decision about an appeal, we will attempt to provide prompt oral notice that more time is needed. We will also send you a letter that explains:

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

You can present additional evidence (such as medical records, supporting statements from a provider, etc.) over the phone, in-person or in writing. You can include the information with your appeal request or submit it at any time during the appeal process.

For a standard appeal, we have to receive this information within 30 calendar days of us receiving your appeal request. For an expedited appeal, we must receive any supporting information within 72 hours of your appeal request.

At any time during the appeal or state fair hearing process, you or your authorized representative can request copies of your appeal file, free of charge, by contacting Member Services.

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

For appeals involving Medicaid benefits, you or your authorized representative have the right to ask for a Medicaid State Fair Hearing after you complete the Humana appeal process. A state fair hearing must be requested within 120 days from the date on the appeal decision letter. You also have the right to ask for a state fair hearing if Humana does not give you a decision about your appeal within 30 days for a standard appeal or 72 hours for an expedited appeal.

Ask for a fair hearing by contacting:

South Carolina Department of Health and Human Services
Division of Appeals and Hearings
P.O. Box 8206
Columbia, SC 29202

Phone: 803-898-2600
Toll-free: 800-763-9087 
Fax: 803-255-8206 
Email: appeals@scdhhs.gov  
Online: www.scdhhs.gov/appeals#Appeals opens in new window

Your written request for a Medicaid fair hearing must include the following information:

• Your name
• Your member number
• Your Medicaid ID number
• A phone number where we can reach you or your authorized representative

If waiting the usual timeframe for a decision could put your life in danger or make it hard for you to get better or stay healthy, you can ask for a faster fair hearing. You or someone you choose to speak for you, or your doctor, with your written permission, can ask for this faster fair hearing.

You can use our online form opens in new window  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 and tell us how you are dissatisfied with your experience.
• File an appeal for a denied medical service, medical device or prescription medication.

After you file a grievance or appeal with our online form, you will get a confirmation e-mail with details of your submission.

Download and return to us the completed form:

Grievance/Appeal Request Form – English pdf opens in new window
Grievance/Appeal Request Form – Spanish pdf opens in new window

Send your completed Grievance/Appeal Request Form to:

Humana Dual Highly Integrated (HMO D-SNP) in South Carolina
Attn: Grievances and Appeals
P.O. Box 14546
Lexington, KY 40512-4546

You can also submit grievances and appeals by phone. Call Customer Care at 866-432-0001 (TTY: 711), 7 days a week, 8 a.m. – 8 p.m., Eastern time (Oct. 1 – March 31); Monday – Friday, 8 a.m. – 8 p.m., Eastern time (April 1 – Sept. 30).