There’s a difference between a grievance and an appeal. A grievance is a complaint that expresses dissatisfaction with any aspect of the operations, activities or behaviors of a Humana plan, including the provision of plan benefits, such as care provided by in-network healthcare providers. A grievance isn’t submitted to dispute a denied claim or service; an appeal is used in these cases. Humana may take up to 30 days from the date it receives a grievance to respond. Visit our Medicare grievance page for detailed information on how to submit a grievance by mail, fax or phone.

Humana Medicare members can also use our online form to submit a grievance.

An appeal is a request for Humana to reconsider the plan’s decision made about the member’s benefits. Some examples of what an appeal may involve are:

• How a claim was denied, partially denied or paid
• A request or authorization for a medical service, medical equipment or prescription that was denied

Visit our Exceptions and appeals  page for information on submitting appeals by mail, fax and phone. Humana Medicare members can also use our online form to submit an appeal. This online form is not used for expedited appeals.

Once Humana receives an appeal, we’ll issue a decision within the following time frames based on what’s being appealed:

• Denied or partially denied medical claim: 60 calendar days
• Denied prescription claim: 14 calendar days
• Denied request or authorization for a medical service or medical equipment: 30 calendar days
• Denied request or authorization for a prescription: 7 calendar days

A request for an expedited (fast) appeal can be submitted if the standard response time frame could seriously jeopardize the member’s life, health or ability to regain maximum function. Expedited appeals aren’t used for claims that have already been paid or denied. Visit our Medicare expedited appeals page for information on submitting an expedited appeal. Humana has 72 hours to respond with a decision after receiving an expedited appeal.

When a request for a grievance or appeal is submitted by someone other than a member, an Appointment of Representative (AOR) form or other types of legal authority documentation is required. Visit our How to appoint a representative page for detailed information and the AOR form. The completed form or document is mailed or faxed with the grievance or appeal. If submitting the grievance or appeal by phone, use the appropriate mailing address or fax number below.

Humana Grievance and Appeal Department
P.O. Box 14165
Lexington, KY 40512-4165
Fax: 855-251-7594