Grievance and appeals

As a Humana Healthy Horizons in Florida member, you can appeal a decision that we make about your healthcare or share a grievance you have with any aspect of your healthcare. We want to hear about this from you and see how we can help.

An appeal is a request for us to reconsider a decision we make. For example:

• Your doctor may ask us for permission for you to have a certain procedure
• Our medical director reviews the request and decides that we cannot give permission (called an Adverse Benefit Determination)
• Get answers to frequently asked questions about how we notify you of an Adverse Benefit Determination
• We send this information to your provider and/or to you
• You and/or your provider disagree with our decision
• You and/or your provider file an appeal

You must file an appeal orally or in writing within 60 calendar days from the date of our decision. An appeal may take up to 30 days to process

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 call Customer Care and feel your wait time is longer than you want to wait
• You visit your doctor and are unsatisfied about an aspect of your visit
• You file a grievance with us to tell us about your experience

You must file a grievance orally or in writing. You can file a grievance at any time after the experience about which you are dissatisfied. A grievance may take up to 90 days to process.

You can find more information about appeals and grievances in your Member Handbook.

If you need an expedited appeal or grievance process, call us at 888-259-6779 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m., Eastern time.

Online

Use our online form to file a grievance or appeal. When filling out the form, please provide as much information as possible.

You can use this form to:

• Submit a grievance and tell us how you are dissatisfied with your experience
• File an appeal for a denied medical service, medical device, and/or prescription medication

After you file a grievance or appeal with our online form:

• You will get a confirmation email with details of your submission

You can get information about the status of any grievance or appeal you submit through our form by:

• Calling the number on the back of your Member ID card to check the status of a grievance
• Using our online appeal tracker to check the status of a medical appeal

In writing

To file a grievance or appeal, you must submit a grievance or appeal form to tell us what happened. Please provide as much information as you can so we can help resolve your issue.

Find grievance and appeal forms

You will need these things to get started:

• Your name, member ID, telephone number and address
• A completed Appointment of Representative (AOR) form, if you are submitting a complaint or appeal on behalf of a Humana member, or another type of representative form (see below section for more information)
• Your service or claim number
• Your provider name
• The date of your service
• The reason you’re submitting the appeal or complaint and what you want to happen
• Any supporting documentation, like receipts for services, medical records, or a letter from your provider that you want to include

Send your completed grievance and appeal form to:

Humana Healthy Horizons in Florida
P.O. Box 14546
Lexington, KY 40512-4546
Attn: Grievance & Appeals Department

You will get a letter from us within 5 business days after we get your appeal or complaint.

By phone

Call Customer Care at 800-477-6931 (TTY: 711), Monday – Friday, from 8 a.m. – 8 p.m., Eastern time.

Find grievance and appeal forms

If you are filing an appeal or grievance on behalf of a member (other than yourself), you need an Appointment of Representative (AOR) form on file with Humana so that you are authorized to work with Humana on the member’s behalf.

You also may use other appropriate legal documentation that shows your authorized representative status (such as power of attorney)

AOR forms are active for one year from the date the form is signed by both the member and the representative, unless revoked.

Download, print, and complete the AOR form, found on the Document and Forms page; sign the form; and return it to us.

Send your completed form to:

Humana Healthy Horizons in Florida
P.O. Box 14546
Lexington, KY 40512-4546
Attn: Grievance & Appeals Department