Insurance through an employer

Grievances, appeals and exceptions

If you're unhappy with some aspect of your coverage or need to make a special request, we want to help. Use these procedures to tell us what's going on. You can also find detailed information in your plan benefit documents about grievances, appeals, and coverage determinations (including exceptions). A coverage determination is advance approval from Humana to cover a drug.

Grievances

A grievance is a complaint about any aspect of your plan—for example, you have problems with the service you receive, or you believe our notices and other written materials are difficult to understand.

See your plan materials for more details about the time frame for filing grievances.

When filing a grievance in writing, please provide all relevant documents. Key information that is required includes the following:

  1. Your name
  2. Your address
  3. Your telephone number
  4. Your Humana ID number
  5. The reason for the grievance

We accept oral grievances or appeals if they are required by state law. When a oral grievance is filed you will be required to supply the information listed above and possibly refer to relevant supporting documentation.

Once we receive your grievance, we’ll investigate it and inform you of our decision.

Appeals

An appeal is a request for us to reconsider our initial decision, if you disagree with our decision to deny payment for an item or service. Please note that appeals should be written—however, we will accept oral appeals as required by law.

See your plan materials for more details about the time frame for appeals.

You can appeal our decision if you think:

  • We're stopping or reducing coverage for an item or service
  • We won't authorize coverage for an item or service we should cover
  • We haven't paid (or fully paid) a bill you believe we should pay
  • We denied an exception on a formulary prescription drug exception request*

Once we receive your appeal, we’ll investigate it and inform you of our decision.

For questions about the appeal process, please call the Customer Care phone number on your Humana ID card.

(*) The formulary exception appeal process may differ from other types of appeals. Please consult your plan document for details on the appeal process and the decision timeframes.

Exceptions

To ask for a prescription drug standard decision or coverage determination, your doctor must contact Humana Clinical Pharmacy Review (HCPR) at 1-800-555-2546 to ask for approval. HCPR is available Monday – Friday, 8 a.m. – 8 p.m., local time. Your doctor also can use tools available on Humana.com/Providers. We will notify your doctor once the request has been processed.

If you prefer, you can deliver a written request to:
Humana Clinical Pharmacy Review (HCPR)
ATTN: Coverage Determinations
P.O. Box 33008
Louisville, KY 40232-3008

Appoint a representative

For Humana to consider an appeal or grievance from someone other than you, we must have a valid authorization. You can appoint anyone as your representative by sending us a signed Humana Appointment of Authorized Representative Form (see link below) or a form approved in advance by Humana.

A representative who is appointed by the court or who is acting in accordance with state law also can file a request on your behalf after sending us the appropriate legal representative document. You don't need to complete an Appointment of Authorized Representative Form if you provide a valid legal representation document with your request instead.

Appointment of Authorized Representative Form – English , PDF opens new window

Appointment of Authorized Representative Form – Spanish , PDF opens new window

Where to file a Grievance or Appeal

For Humana Employer Plans

Via Mail:

Humana Grievances and Appeals
P.O. Box 14546
Lexington, KY 40512-4546

Via Phone:

To file an oral grievance or appeal, call the Customer Care phone number on your Humana member ID card.

Download the Grievance/Appeal Request Form here:

Grievance/Appeal Request Form – English , PDF opens new window

Grievance/Appeal Request Form – Spanish , PDF opens new window