Grievances, appeals and exceptions

If you’re unhappy with your Humana coverage, or want to make a special request, we want to help. A grievance, appeal or exception gives you the chance to tell us what’s on your mind so we can work to find a solution.

All members with Medicare, Medicaid and prescription drug coverage have the right to file these requests. Here’s some information to help you get started with your grievance, appeal or exception.

A customer care representative makes a call from her office using a headset.

Grievances, appeals and exceptions explained

  • Grievance—A grievance is a complaint about any aspect of your Medicare plan. For example, if you received poor service or you think our plan notices are hard to understand.
  • Appeal—An appeal, or redetermination, is a request for us to reconsider an initial decision you disagree with. Examples include a denial of payment or coverage for a service.
  • Exceptions—Exceptions are a type of coverage determination for prescriptions drugs. These requests may include covering drugs not currently on Humana’s Drug List or waiving certain limits.

Who can submit grievances, appeals and exceptions

  • Medicare Part C (Medicare Advantage)—You (member), a person you appoint or your physician.
  • Medicare Part D (Prescription drug coverage)—You (member), a person you appoint, your prescribing doctor or other prescriber.

How to submit grievances, appeals and exceptions

Online

Mail or fax

Download a form, fill it out and send it to the address or fax number on the form:

Puerto Rico members use the following forms:

Note: Be sure to submit any required supporting documents (receipts, medical records or a letter from your doctor) with your form.


Phone

To file an oral grievance, appeal or exception, call the Customer Care number on the back of your Humana member ID card. You can also get help with any questions or problems you have filling out the form, or check the status on a previously filed appeal. If you have a speech or hearing impairment and use a TTY, call 711. Puerto Rico members should call 866-773-5959.

Expedited appeals

Expedited appeals are only appropriate for services that haven’t yet been rendered and if you and your provider believe that waiting for a standard decision could seriously harm your life, health or ability to regain maximum function. Here are the ways to submit an expedited appeal:

  • Phone—800-867-6601 (Puerto Rico members should call 866-773-5959)
  • Fax (Part D only)—Download a Appeal, Complaint and Grievance form, fill it out and check the box in the “Does your appeal need to be expedited?” section. Once complete, fax the form to the number on the form. 
  • Mail—Download a copy of the Appeal, Complaint or Grievance Form, fill it out and mail it to:

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

    • Puerto Rico members can mail it to:

      Humana Puerto Rico Expedited Appeals Unit
      P.O. Box 191920
      San Juan, PR 00919-1920

Employer plans

To file a grievance or appeal for a Humana Employer plan, download a Appeal, Complaint and Grievance form, fill it out and mail it to:

Humana Grievances and Appeals
P.O. Box 14546
Lexington, KY 40512-4546

You can also file an oral grievance or appeal by calling the Customer Care number on your Humana member ID card.

Important timeframes for appeals

  • Part C— You have 65 days from the date of our Noticie of Denial of Medical Coverage (or Payment) to appeal. After we receive the request, Humana will make a decision and send written notice within the following timeframes:
    • Pre-Service Appeal—30 Calendar Days
    • Post Service Appeal—60 Calendar Days
  • Part D—You have 65 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to appeal (ask us for a redetermination). After we receive the request, Humana will make a decision and send written notice within 7 calendar days.

How to appoint a representative to file for you 

For Humana to consider an appeal or grievance from someone other than you, we must have a valid authorization. You can appoint anyone as your representative by signing and sending us 1 of the following forms:

A representative who is appointed by the court or who is acting in accordance with state law also can file a request on your behalf after sending us the appropriate legal representative document. You don't need to complete an Appointment of Authorized Representative form if you provide a valid legal representation document with your request instead.

How to appeal a Part D late enrollment penalty from the Centers for Medicare & Medicaid Services (CMS)

If you received a Part D late enrollment penalty, you can appeal the decision with CMS if you meet certain conditions. Learn more about a Part D late enrollment penalty reconsideration to see if you qualify, how to appeal this decision and more.