South Carolina Medicaid: Grievances and appeals

As a Humana Healthy Horizons in South Carolina 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, other than an adverse determination. For example:

• 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.

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

• We deny a claim that your doctor sends us to pay for services you get
• We deny your doctor’s request for you to have a certain procedure (called an Adverse Benefit Determination)

If you and/or your doctor 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-day timeframe 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 866-432-0001 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m.

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:

• An member or provider who files an appeal
• A provider that supports an member’s appeal or files an appeal on behalf of an member with written consent

You have the right to ask for a State Fair Hearing from the Department for Medicaid Services, after you complete the Humana appeal process. You must ask for a hearing within 120 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.

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

South Carolina Department of Health and Human Services Division of Appeals and Hearings
1801 Main Street
P.O. Box 8206
Columbia, SC 29202

Phone Number: 803-898-2600
Toll-Free Phone: 800-763-9087
Fax Number: 803-255-8206
Email: appeals@scdhhs.gov
Website: https://msp.scdhhs.gov/appeals/

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.

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

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

To file a grievance or appeal by mail or by 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 South Carolina
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.

Call Member Services at 866-432-0001 (TTY: 711), Monday – Friday, from 8 a.m. – 8 p.m., Eastern time. We will get some information from you and start the grievance or appeal process.

If you are filing a grievance or appeal on behalf of a Humana Healthy Horizons in South Carolina 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 South Carolina
Attn: Grievance & Appeal Department
P.O. Box 14546
Lexington, KY 40512-4546

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

You can learn more about the grievance and appeal process in your Member Handbook.