Medical organization determination

You have the right to ask Humana to pay for items or services you think should be covered also called a coverage decision. If you are a Medicare member, this is called a request for "organization determination.”

An organization determination (referred to here as a coverage decision) is a decision Humana makes about your benefits and coverage and whether we will pay for the medical services you or your doctor have requested. You can also contact us to ask for a coverage decision before you receive certain medical services. You might want to ask us to make a coverage decision beforehand if your doctor is unsure whether we will cover a particular medical service or if your doctor refuses to provide medical care you think you need.

You, your representative, or your doctor can ask us for a coverage decision by calling, writing, or faxing your request to us.

Make a free call to 1-800-457-4708. You can call us seven days a week, from 8 a.m. - 8 p.m. Eastern time. However, please note that our automated phone system may answer your call during weekends from February 15 - September 30 or on some holidays. Please leave your name and telephone number, and we’ll call you back by the end of the next business day.

For fast (expedited) coverage decisions, call 1-866-737-5113.

If you belong to a Group Medicare plan, please contact Humana Medicare Employer Plan at the number on the back of your member card or, for TTY users, 711, Monday through Friday, from 8 a.m. - 9 p.m. Eastern time. Our automated phone system may answer your call on Saturdays, Sundays, and some public holidays. Please leave your name and telephone number, and we'll call you back by the end of the next business day. Customer Care also has free language interpreter services available for non-English speakers.

TTY 711

Calls to this number are free. You can call us seven days a week, from 8 a.m. - 8 p.m. Please note that our automated phone system may answer your call during weekends from February 15 - September 30 or on some holidays. Please leave your name and telephone number, and we’ll call you back by the end of the next business day.

This number requires special telephone equipment and is only for people who have difficulties hearing or speaking.

Fax

1-888-200-7440

Contact us by fax for expedited coverage decisions only.

Write

When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “expedited” (fast) deadlines. A “fast coverage decision” is called an “expedited determination.”

Standard coverage decision

A standard coverage decision means we will give you an answer within 14 days of receiving your request.

Expedited (fast) coverage decision

If you think your health could be seriously harmed or that you could lose your ability to function by waiting the standard 14 days for a decision, you can ask for an “expedited” (fast) decision. We will give you an answer with 72 hours after we receive your request for a fast coverage decision.

To get a fast coverage decision, you must meet two requirements:

• You must be asking for coverage for medical care you have not yet received. (You cannot get a fast coverage decision if your request is about payment for medical care you have already received.)
• You must need a fast decision because using the standard deadlines could cause serious harm to your health or hurt your ability to function.

If your doctor tells Humana that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision.

If you ask for a fast coverage decision on your own, without your doctor's support, we will decide whether your health requires that we give you a fast coverage decision.

• If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead).
• This letter will explain that we will automatically give a fast coverage decision if your doctor asks for it.
• The letter will also explain how you can file a “fast complaint” about our decision to give you a coverage decision using the standard deadline. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.

We can take up to 14 more calendar days to make either a standard or fast decision if you ask for more time or if we need information (such as medical records from out-of-network providers) that may benefit you. If we decide to take extra days to make the decision, we will tell you in writing.

If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your complaint within 24 hours.

If we do not give you our answer within the standard or fast time (or if there is an extension at the end of that period), you have the right to appeal. You also have the right to file an appeal if you disagree with our coverage decision.

In some cases we might decide a service is not covered or is no longer covered by your plan. If we say no to part or all of what you requested, we will send you a detailed written explanation as to why we said no and instructions on how to appeal our decision.See more information about how to file an appeal.

For some types of items or services, your doctor may need to get approval in advance from our plan (this is called getting "prior authorization"). Those services that require advance approval are included in your Evidence of Coverage.