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 time frame 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 time frame 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?
Fax or mail the form
Download a copy of the following form and fax or mail it to Humana:
Fax number:
1-855-251-7594
Mailing address:
Humana Grievances and Appeals
P.O. Box 14165
Lexington, KY 40512-4165
Puerto Rico members:
Use the following form and fax and/or mailing address:
Fax number:
1-800-595-0462
Mailing address:
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 5 a.m. to 8 p.m. EST, 7 days a week.
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:
- Pre-Service Appeal – Within 30 Calendar Days
- Post Service Appeal– Within 60 Calendar Days