South Carolina Medicaid: Grievances and appeals
If you have a grievance or appeal related to Humana Healthy Horizons® in South Carolina or any aspect of your care, we want to hear about it and see how we can help.
If you have a grievance or appeal related to Humana Healthy Horizons® in South Carolina or any aspect of your care, we want to hear about it and see how we can help.
As a Humana Healthy Horizons in South Carolina member, you can:
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 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:
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:
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:
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: , opens new window
You can submit a grievance or appeal to us:
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:
After you file a grievance or appeal with our online form:
You can get information about the status of any grievance or appeal you submit through our form by:
To file a grievance or appeal by mail or by fax, please
include the following 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. You still must send an official request in writing by:
If you are filing a grievance or appeal on behalf of a Humana Healthy Horizons in South Carolina member, you must submit a completed , PDF opens new window, 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 , PDF opens new window.This form requires a handwritten signature.
Send your completed form to:
Humana Healthy Horizons™ in South Carolina
Fax your completed form to us at 800-949-2961.
You can learn more about the grievance and appeal process in your Member Handbook.