Ohio Medicaid: Grievances and appeals
If you have a grievance or appeal related to Humana Healthy Horizons® in Ohio or any aspect of your care, we want to hear about it and see how we can help.
If you have a grievance or appeal related to Humana Healthy Horizons® in Ohio or any aspect of your care, we want to hear about it and see how we can help.
As a Humana Healthy Horizons in Ohio member, you can:
After we hear from you, we will see how we can help.
A grievance is a formal complaint or dispute expressing dissatisfaction with any aspect of the operations, activities, or behavior of Humana or its providers. For example:
You may file a grievance in writing, online, or orally. You can file a grievance at any time after the experience about which you are dissatisfied.
We will respond to your grievance within the following time frames:
If we need more time to make a decision about a grievance, we will send you a letter that explains:
If you think we need more time to make a decision about a grievance, you can ask us to take up to 14 calendar days.
You also have the right to file a grievance (complaint) at any time by contacting the:
Ohio Department of Medicaid
Bureau of Managed Care Compliance and Oversight
P.O. Box 182709
Columbus, OH 43218-2709
800-605-3040 or 800-324-8680
Ohio Department of Insurance
50 W. Town St.
3rd Floor – Suite 300
Columbus, OH 43215
800-686-1526
An appeal is a request for us to reconsider a decision we make. For example:
If you and/or your provider disagree with our decision, you can file an appeal and ask us to reconsider.
You may file an appeal in writing, online, or orally within 60 calendar days from the date of our adverse benefit determination. An appeal may take up to 15 days to process.
If waiting the 15-day time frame to resolve an appeal could seriously harm your health, you can ask us to expedite your appeal.
If you need us to expedite your appeal, you or your authorized representative can call us at 877-856-5702 (TTY: 711), Monday – Friday, 7 a.m. – 8 p.m., Eastern time.
For us to expedite your appeal, waiting could seriously jeopardize your:
We make decisions on expedited appeals within 72 hours or as fast as needed based on your health. Negative actions will not be taken against:
If we do not change our decision or action because of your appeal, we will notify you of your right to request a state hearing. You may only request a state hearing after you have gone through our appeal process.
You have the right to ask for a state fair hearing from the Ohio Department of Medicaid after you complete the Humana Healthy Horizons in Ohio appeal process. You must ask for a hearing within 120 days from the date on our appeal decision letter. You must send your request for a state fair hearing in writing, by mail or fax, with a signature.
A state hearing is a meeting with you or someone you want to speak on your behalf, someone from the County Department of Job and Family Services, someone from Humana Healthy Horizons in Ohio, and a hearing officer from the Bureau of State Hearings within the Ohio Department of Job and Family Services (ODJFS).
In this meeting:
The hearing officer will listen and then decide who is right based on the rules and the information given.
To request a state fair hearing, send your completed request to:
Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings
P.O. Box 182825
Columbus, OH 43218-2825
Or by:
Email:
Call: 866-635-3748
Fax: 614-728-9574
For additional help, call the ODJFS Consumer Access Line at 866-635-3748.
If you want information on free legal services:
You can submit a grievance or appeal to us:
You also can start the grievance or appeal process by phone but will need to provide information to us in writing as well.
When you submit a grievance or appeal, please provide as much information as possible.
Use our online form to:
After you file a grievance or appeal with our online form:
You can get information about the status of any grievance or appeal you submit through our form by:
To file a grievance or appeal by mail or fax, please include the following information:
To submit your grievance or appeal by mail, send the above information to:
Humana Healthy Horizons in Ohio
Attn: Grievance & Appeal Department
P.O. Box 14546
Lexington, KY 40512-4546
To submit your grievance or appeal by fax, fax the above information to 800-949-2961.
We will send you a letter within 5 business days from the day we get your grievance or appeal form, to let you know that we received the information.
Call Member Services at 877-856-5702 (TTY: 711), Monday – Friday, 7 a.m. – 8 p.m., Eastern time. We will get some information from you and start the grievance or appeal process. You still must send an official request in writing by:
If you are filing a grievance or appeal on behalf of a Humana Healthy Horizons in Ohio member, you must submit a completed Appointment of Representative (AOR) Form, or other type of representative form (e.g., power of attorney), along with the other information listed above.
An authorized representative is a trusted person (e.g., family member, friend, provider, or attorney) that you appoint to speak on your behalf for purposes of the grievance or appeal process.
Submitting an AOR Form tells us that you are authorized to work with us on the member’s behalf.
An AOR Form is active for 1 year from the date you and our member sign the form, unless revoked. Download, print, and complete an AOR Form. This form requires a handwritten signature.
Send your completed form to:
Humana Healthy Horizons in Ohio
Attn: Grievance & Appeal Department
P.O. Box 14546
Lexington, KY 40512-4546
Fax your completed form to us at 800-949-2961.
More on grievances and appeals