The external medical review process:
- Is available at no cost to the provider
- Does not interfere with the provider’s right to request a peer-to-peer review
- Does not interfere with a member’s right to request an appeal or state hearing
A provider must submit a request for an external medical review within 30 calendar days of receiving the Humana Healthy Horizons decision.
You can file an external medical review verbally or in writing. To file an external medical review:
- Call 1-800-448-3810 (TTY: 711)
- Send a written grievance to us with the following information:
- Member name
- Member identification number from the front of the member’s Humana Healthy Horizons member ID card
- Member address and phone number
- Explanation of issue
Send this written information to:
Humana Healthy Horizons in Louisiana
Grievance and Appeal Department
P.O. Box 14546
Lexington, KY 40512-4546
Or fax this written information to 1-800-949-2961.
Following the external medical review, a letter is sent within:
- 24 hours for requests associated with expedited service authorization decisions
- 30 days for requests associated with standard service authorization decisions
- 60 days for requests associated solely with provider payment(s)
The external medical review decision is final and binding. If the external medical review determination is reversed, Humana Healthy Horizons will authorize the services within 72 hours or pay for the disputed service within the time frames established for claims payment.
See the Humana Healthy Horizons in Louisiana Provider Manual for other information about the grievances and appeals process.