When can I appeal an unfavorable Part C coverage determination?
If you have received an unfavorable Part C determination, you can ask for a reconsideration (appeal) by following the instructions given in the determination or as outlined below. Reconsiderations can be requested on any adverse determination. An expedited reconsideration can be requested if you believe that waiting for a decision under the standard timeframe could seriously jeopardize the life or health of the member, or the ability to regain maximum function.
Can I file an expedited appeal on an adverse initial determination?
An expedited appeal can be requested if you believe that waiting for a decision under the standard timeframe could seriously jeopardize the life or health of the member, or the ability to regain maximum function. Refer to the Expedited Appeal section.
Who can submit the Part C reconsideration (appeal) request?
You (member), a person you appoint, or your physician. Refer to the How to Appoint a Representative section for additional information.
How can I submit the Part C reconsideration request?
Grievance/Appeal Request Form
Fax Number: 1-855-251-7594
Humana Grievances and Appeals
P.O. Box 14165
Lexington, KY 40512-4165
Puerto Rico Members: Use the following form, fax and/or mailing address.
Fax Number: 1-800-595-0462
Humana Puerto Rico
Grievances and Appeals Unit
P.O. Box 191920
San Juan, PR 00919-1920
If you need assistance, call Customer Service – You can get help with any questions or problems you have filling out the form by calling Customer Service toll free at the number on the back of your ID card.
If you have a speech or hearing impairment and use a TTY, call 711. For Puerto Rico members, call 1-866-773-5959. Our hours are 8 a.m. to 8 p.m. Monday through Friday EST.
Be sure to submit all supporting documentation, along with your appeal request. After we receive the request, Humana will make a decision and send written notice within the following timeframes:
Humana is a Medicare Advantage organization and a stand-alone prescription drug plan with a Medicare contract. Enrollment in a Humana plan depends on contract renewal.
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