If the Humana Behavioral Health physician reviewer determines that the care requested does not meet the medical necessity clinical criteria and sends an adverse determination letter, there are steps the enrollee, practitioner or facility may take to have a different physician reviewer consider the request for services. The enrollee, practitioner or facility may appeal any adverse determination either orally or in writing within 180 days of receipt of the adverse determination. Standard appeals are resolved within 30 calendar days (or 15 calendar days for HMO accounts) Humana Behavioral Health receives the request for the appeal.
An expedited appeal is a request for review of emergency care, care for life-threatening conditions, or continued stays for hospitalized patients. An expedited appeal determination is made within 72 hours of the request for appeal. In many states, the enrollee has the right to appeal to the health plan, the state department of insurance, or to an external review organization not affiliated with Humana Behavioral Health. Please note: Some states require a more stringent appeal turn around time. In such cases, Humana Behavioral Health will process the appeal within the state required time frame.