Humana

Appeal Deadlines

Commercial: 180 days from denial date

Medicare: 60 days for Medicare Advantage

Key Facts

• +Humana has one of the lower Medicare Advantage prior authorization denial rates among major insurers at 5.8%, compared to UHC at 12.8%.
• +Humana was rated by 64% of physicians as having high or extremely high prior authorization burden -- second only to UHC.
• +Humana was named in the Senate investigation report on algorithm-based Medicare Advantage claim denials for post-acute care.
• +Humana has a significant Medicare Advantage presence and many of its members are seniors managing multiple conditions.

What to Watch

• +If you are in a Humana Medicare Advantage plan and were denied post-acute care such as skilled nursing or inpatient rehab, request documentation of how the denial decision was made and whether an algorithm was used.
• +Humana's prior authorization requirements for Medicare Advantage can differ significantly from Original Medicare coverage rules.

Appeal Tips

1. For Medicare Advantage denials, request that a licensed clinician -- not an automated system -- review your appeal.
2. Include your treating physician's clinical assessment and recommended course of treatment in your appeal.
3. If your appeal is denied internally, you have the right to an Independent Review Organization (IRO) review. This is separate from Humana and the decision is binding on Humana.

Resources

• Humana Member Appeals