addresses

Medical claim payment reconsiderations and appeals

This web page contains information for Humana participating and nonparticipating physicians, hospitals and other health care providers about medical claim payment reconsiderations and member appeals.

Information for participating providers

Participating providers may find the reconsideration processes in the provider manuals for physicians, hospitals and health care providers. The manuals are available at Humana.com/publications.

Information for nonparticipating providers

Medicare Advantage plans: appeals for nonparticipating providers

In order to request an appeal of a denied claim, you need to submit your request in writing within 60 calendar days from the date of the denial. This request should include:

  • A copy of the original claim
  • The remittance notification showing the denial
  • Any clinical records and other documentation that support your case for reimbursement

You need to include a signed Waiver of Liability form holding the enrollee harmless, regardless of the outcome of the appeal. Once you have completed the request, please mail it to:

Humana P.O. Box 14165 Lexington, KY 40512-4165

In Puerto Rico, please use this address:

Humana Unidad de Querellas y Apelaciones P.O. Box 195560 San Juan, PR 00919-5560

Commercial plans: appeals for nonparticipating providers

If you believe the determination of a claim is incorrect, you may file an appeal on behalf of the covered person with authorization from the covered person. Some states may allow providers to file on their own behalf in certain circumstances. Please review the applicable state law for appeal rights.

The appeal will be reviewed by parties not involved in the initial determination. In order to request an appeal, you need to submit your request in writing within the time limits set forth in the medical insurance policy if filing on behalf of the covered person. If filing on your own behalf, you need to submit your written request within the time frame established by applicable state law. Please send the appeal to the following address:

Humana Grievance & Appeals Office P.O. Box 14546 Lexington, KY 40512-4546

In Puerto Rico, please use this address:

Humana Unidad de Querellas y Apelaciones P.O. Box 191920 San Juan, PR 00919-1920

Please include with your request:

  • A copy of the original claim
  • The explanation of remittance showing the denial
  • Any clinical records and other documentation that support your case for reimbursement
  • An Appointment of Representative (AOR) Form or other legal documentation authorizing you to act on the covered person’s behalf (if you are filing an appeal on behalf of a covered person)

Please note that the commercial plan appeals process is the same for nonparticipating and participating providers.

Medicaid plans: reconsiderations for nonparticipating providers

If you believe the determination of a claim is incorrect, please review your state laws and/or the applicable provider handbook for reconsideration rights. The reconsideration request will be reviewed by parties not involved in the initial determination.

In order to request a reconsideration, you need to submit your request in writing within the applicable time frame specified in state law. In addition to any other documents required by applicable law or state procedures, this request should include:

  • A copy of the original claim
  • The remittance notification showing the denial
  • Any clinical records and other documentation that support your case for reimbursement

Reconsideration requests containing the documents listed above should be mailed to:

Humana Grievance & Appeals Office P.O. Box 14546 Lexington, KY 40512-4165