Humana Appeal Florida 2026: Complete Guide for Medicaid & Medicare

If you've received a Humana denial in Florida and searched for "Humana appeal guide," you may have found generic national guides that miss Florida-specific details. Humana operates multiple distinct plan types in Florida, each with unique appeal processes, timelines, and contact information.

This comprehensive guide provides Florida-specific appeal letter templates for Humana Healthy Horizons (Medicaid) and Humana Medicare Advantage plans, explains the critical differences between Medicaid and Medicare appeals in Florida, and shows you exactly how to submit appeals that achieve 72-80% overturn rates.

Why Humana Florida Appeals Are Different: Medicaid vs Medicare

Unlike other states where Humana primarily offers one product line, Florida has multiple Humana entities with completely separate appeal procedures. Using the wrong process, address, or timeline will delay or reject your appeal.

The 3 Humana Florida Plan Types

1. Humana Healthy Horizons in Florida (Medicaid)

• Who has this: Florida Medicaid recipients, low-income families, pregnant women, children, disabled adults
• How to identify: Member ID card says "Humana Healthy Horizons" or portal is humana.com/medicaid/florida-medicaid
• Appeal address: P.O. Box 14546, Lexington, KY 40512-4546, Attn: Grievance and Appeals
• Phone: 800-477-6931 (Customer Care) or 888-259-6779 (expedited)
• Member deadline: 60 calendar days from denial date
• Provider deadline: 90 calendar days from denial date
• Decision timeline: 30 days standard, 72 hours expedited
• Unique feature: 5-day acknowledgment letter required by Florida Medicaid regulations

2. Humana Medicare Advantage (Part C - Medical)

• Who has this: Florida seniors 65+, younger people with disabilities on Medicare
• How to identify: Card says "Humana Gold," "HumanaChoice," or "Humana Medicare Advantage"
• Appeal address: P.O. Box 14165, Lexington, KY 40512-4165 (for reconsiderations)
• Phone: Number on back of member ID card
• Deadline: 65 calendar days from Notice of Denial
• Decision timeline: 7 calendar days (2026 CMS requirement, reduced from 30 days)
• Unique feature: If Humana misses 7-day deadline, appeal automatically advances to Independent Review Entity (IRE)

3. Humana Medicare Part D (Prescription Drugs)

• Who has this: Medicare beneficiaries with Humana prescription drug coverage
• How to identify: Separate Part D card or combined Medicare Advantage + Part D card
• Appeal process: Called a "redetermination" (not "appeal")
• Deadline: 65 calendar days from Notice of Denial of Medicare Prescription Drug Coverage
• Decision timeline: 7 calendar days standard, 72 hours expedited
• Unique feature: Can be filed by member, prescriber, or appointed representative

Why These Differences Matter

Wrong Address = Delayed Appeal: Mailing a Medicaid appeal to the Medicare Advantage address will delay processing by 2-3 weeks while Humana forwards it internally.

Wrong Deadline = Rejected Appeal: Medicare Advantage has a 65-day deadline (not 60 or 180 days). Missing this by one day means automatic rejection and you lose all appeal rights.

Wrong Process = Wasted Time: Part D appeals are called "redeterminations" and use a completely different form and process than Part C medical appeals. Using the wrong form means starting over.

Florida-Specific Humana Denial Reasons (And How to Counter Them)

Humana's Florida denial patterns differ from national averages due to Florida's high Medicare Advantage enrollment (51% of Medicare beneficiaries), unique Medicaid managed care regulations, and Humana's use of NaviHealth AI for utilization review.

Top 5 Humana Florida Denials in 2026

1. "Post-Acute Care Not Medically Necessary" (24.6% of PAC requests denied)

Why Humana denies: According to a 2024 Senate investigation, Humana's post-acute care denial rate (24.6%) is 16 times higher than its overall Medicare Advantage denial rate (3.5%). Humana uses NaviHealth, an AI-driven utilization management system acquired by Optum, which increased denial rates by 54% between 2020-2022 for long-term acute care hospitals.

How to counter:

• Request peer-to-peer review between treating physician and Humana medical director (85% success rate)
• Cite specific Humana Medical Coverage Policies showing criteria are met
• Include physician documentation showing ongoing medical necessity
• For Florida Medicaid: Reference Florida Admin. Code for post-acute care standards

2. "Prior Authorization Not Obtained" (18% of denials)

Why Humana denies: Humana had 3.1 prior authorizations per enrollee in 2023—among the highest of all Medicare Advantage insurers. Florida practices often miss Humana's extensive prior auth list, which includes advanced imaging, specialty drugs, DME, and many outpatient procedures.

How to counter:

• Demonstrate emergency circumstances (no time for PA)
• Show PA was submitted via Availity but not processed by Humana
• Provide documentation that service meets "urgent care" exception
• For retrospective PA: Submit clinical notes proving medical necessity at time of service

3. "Medical Necessity Not Established" (22% of denials)

Why Humana denies: Clinical documentation doesn't match Humana's Medical Coverage Policies (MCPs). Florida reviewers strictly enforce MCP criteria, especially for high-cost services like surgery, biologics, and advanced imaging.

How to counter:

• Cite specific Humana MCP number and section showing case meets criteria
• Include physician notes demonstrating failed conservative treatments
• Reference peer-reviewed studies and clinical practice guidelines
• For Healthy Horizons: Cite Florida Medicaid coverage policy in addition to Humana MCP

4. "Service is Experimental/Investigational" (8% of denials)

Why Humana denies: Humana classifies treatments as experimental if they lack FDA approval, sufficient clinical evidence, or inclusion in Humana's technology assessment bulletins—even if other insurers cover them.

How to counter:

• Provide FDA approval documentation
• Cite medical society guidelines recommending the treatment
• Show widespread clinical acceptance (usage by peer physicians)
• Include peer-reviewed studies demonstrating efficacy

5. "Out-of-Network Provider" (12% of denials for HMO plans)

Why Humana denies: Humana HMO plans (common in Florida Medicaid) require in-network providers except for emergencies. Many Florida specialists don't participate in Humana Healthy Horizons networks.

How to counter:

• Demonstrate no in-network specialist available within 50 miles
• Show medical emergency required immediate out-of-network care
• Provide documentation that Humana's network directory incorrectly listed provider as in-network
• Request single-case agreement for out-of-network specialist

Step-by-Step: How to Appeal a Humana Denial in Florida

Step 1: Identify Your Humana Plan Type (5 minutes)

Check your member ID card:

• "Humana Healthy Horizons" → Medicaid plan, use Medicaid appeal process
• "Humana Gold," "HumanaChoice," Medicare logo → Medicare Advantage, use Part C process
• Separate prescription card → Part D appeals for drug denials

Can't tell from card? Log into your Humana member portal or call the phone number on your card and ask, "Do I have Medicaid, Medicare Advantage, or commercial insurance?"

Step 2: Gather Required Documentation (15-20 minutes)

For all appeal types, you need:

• Denial letter or Notice of Denial (includes claim number, denial reason, appeal rights)
• Member ID card (front and back copy)
• Itemized bills or Explanation of Benefits (EOB)
• Medical records supporting medical necessity

Additional documents by denial reason:

• Medical necessity denials: Physician notes, treatment history, diagnostic test results
• Prior auth denials: Documentation showing PA was requested or emergency circumstances
• Experimental denials: FDA approval letters, clinical guidelines, peer-reviewed studies
• Network denials: Proof of network directory error or lack of in-network alternatives

Step 3: Write Your Appeal Letter Using Florida-Specific Template (30-45 minutes)

Humana Healthy Horizons (Medicaid) Appeal Template

[Your Name]
[Your Address]
[City, State, ZIP]
[Phone Number]
[Date]

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

RE: Appeal of Adverse Benefit Determination
Member Name: [Full Name]
Member ID: [Humana Healthy Horizons ID]
Date of Birth: [MM/DD/YYYY]
Claim Number: [From denial letter]
Date of Service: [MM/DD/YYYY]
Provider NPI: [10-digit NPI if provider appeal]

Dear Humana Healthy Horizons Appeals Department,

I am writing to appeal the denial of [specific service/procedure] dated [denial letter date]. Humana denied this claim stating "[exact denial reason from letter]." I am requesting a full reconsideration of this decision.

MEDICAL NECESSITY JUSTIFICATION:
[Procedure/service] was medically necessary because [explain clinical rationale]. The patient's medical history includes [relevant diagnoses, previous treatments, failed conservative therapy].

According to Humana Medical Coverage Policy [MCP number], coverage is provided when [cite specific coverage criteria]. This case meets all required criteria:
1. [Criterion 1]: [Explain how met with supporting documentation]
2. [Criterion 2]: [Explain how met with supporting documentation]
3. [Criterion 3]: [Explain how met with supporting documentation]

FLORIDA MEDICAID COVERAGE:
Florida Medicaid covers this service under [cite Florida Admin Code or Medicaid Coverage Policy]. As a Florida Medicaid managed care plan, Humana Healthy Horizons must provide services covered by Florida Medicaid unless specifically excluded.

SUPPORTING CLINICAL EVIDENCE:
- Attached: Physician notes from [date] documenting medical necessity
- Attached: Diagnostic test results showing [clinical findings]
- Attached: Treatment history showing failed conservative management

REQUESTED RESOLUTION:
I request that Humana overturn this denial and provide coverage for [service/procedure] as submitted. Under Florida Medicaid regulations, I expect a written decision within 30 days and a 5-day acknowledgment of receipt.

If this appeal is denied, please provide:
1. Specific Humana Medical Coverage Policy sections cited for denial
2. Clinical reviewer's credentials and specialty
3. Information about requesting external review through Florida AHCA

Thank you for your prompt attention to this matter.

Sincerely,
[Signature]
[Printed Name]
[Title if provider: MD, DO, NP, etc.]

Enclosures:
- Copy of denial letter
- Medical records (pages X-X)
- Diagnostic test results
- Supporting clinical documentation

Humana Medicare Advantage (Part C) Appeal Template

[Your Name or Practice Name]
[Address]
[City, State, ZIP]
[Phone Number]
[Date]

Humana Inc.
Medicare Reconsiderations
P.O. Box 14165
Lexington, KY 40512-4165

RE: Medicare Advantage Appeal (Organization Determination)
Member Name: [Full Name]
Member ID: [Humana Medicare ID]
Date of Birth: [MM/DD/YYYY]
Claim Number: [From Notice of Denial]
Date of Service: [MM/DD/YYYY]

Dear Humana Medicare Appeals Department,

This letter constitutes a formal appeal of the denial dated [denial date] for [specific service]. Under CMS regulations at 42 CFR § 422.562, I am requesting an organization determination within 7 calendar days as required for 2026.

DENIAL INFORMATION:
Date of Denial: [MM/DD/YYYY]
Reason Stated: "[Exact denial reason]"
Claim Amount: $[amount]

MEDICARE COVERAGE CRITERIA:
According to CMS National Coverage Determination (NCD) [number if applicable] or Local Coverage Determination (LCD) [number], [service] is covered when [cite LCD/NCD criteria]. This case meets all Medicare coverage requirements:

1. [Medicare criterion 1]: [Documentation showing how met]
2. [Medicare criterion 2]: [Documentation showing how met]
3. [Medicare criterion 3]: [Documentation showing how met]

HUMANA MEDICAL COVERAGE POLICY COMPLIANCE:
Humana Medical Coverage Policy [MCP number] requires [criteria]. Attached documentation demonstrates:
- [Specific evidence meeting MCP criterion 1]
- [Specific evidence meeting MCP criterion 2]
- [Specific evidence meeting MCP criterion 3]

CLINICAL JUSTIFICATION:
The treating physician notes (attached) document that [service] was medically necessary due to [clinical explanation]. Conservative treatments attempted include [list treatments tried and outcomes].

FLORIDA PATIENT PROTECTIONS:
Under Florida's patient protection statutes, Medicare Advantage enrollees have the right to timely appeal decisions. Florida law requires insurers to maintain 7-day-per-week appeal review capabilities.

2026 CMS REQUIREMENT:
Under the Contract Year 2026 Final Rule (CMS-4208-F), Humana must issue a decision within 7 calendar days. If this deadline is not met, my appeal automatically advances to the Independent Review Entity (IRE) per CMS regulations.

REQUESTED ACTION:
Overturn the denial and approve coverage for [service] as billed. Provide written decision within 7 calendar days including specific policy citations if denied.

If denied, please provide:
- Name and credentials of reviewing physician
- Specific MCP sections cited
- Instructions for IRE appeal

Thank you for prompt processing.

Sincerely,
[Signature]
[Printed Name]

Enclosures:
- Notice of Denial
- Clinical documentation
- Medicare LCD/NCD citation
- Physician statement of medical necessity

Step 4: Submit Your Appeal (10 minutes)

Humana Healthy Horizons (Medicaid) submission methods:

• Mail (recommended for documentation): P.O. Box 14546, Lexington, KY 40512-4546, Attn: Grievance and Appeals
• Phone (for expedited): 888-259-6779, Monday–Friday, 8 a.m.–8 p.m. ET
• Online: resolutions.humana.com/grievances-appeals-forms/member-info
• Fax: Number provided on denial letter (varies by region)

Humana Medicare Advantage submission methods:

• Mail: P.O. Box 14165, Lexington, KY 40512-4165
• Availity (providers only): Submit via Claim Status tool → "Dispute Claim"
• Phone: Number on member ID card for expedited processing
• Fax: 855-352-1206 (for providers)

Submission tips:

• Send via USPS Certified Mail with return receipt for proof of timely filing
• Keep copies of everything you submit
• Note submission date on calendar (to track 7-day or 30-day decision deadline)
• Include cover letter listing all attachments

Step 5: Track Your Appeal Status (5 minutes)

Within 5 business days, you should receive acknowledgment letter confirming:

• Appeal received date
• Assigned appeal ID number
• Expected decision date
• Contact information for status updates

How to check status:

• Humana Healthy Horizons: Call 800-477-6931 and provide appeal ID
• Medicare Advantage: Log into member portal or call number on ID card
• Providers: Check Availity Essentials → Appeals Worklist

If you don't receive acknowledgment within 5 business days:

• Call Humana immediately
• Confirm they received your appeal
• Request appeal ID number and confirmation of receipt date

How Muni Appeals Automates Humana Florida Appeals

Your staff spends 45-60 minutes per Humana appeal researching Medical Coverage Policies, compiling clinical documentation, and formatting appeal letters. For a practice handling 15-20 denials monthly, that's 12-15 hours of lost productivity.

Muni Appeals automates the entire Humana appeal process:

Florida Plan-Specific Intelligence:

• Auto-detects Humana Healthy Horizons (Medicaid) vs Medicare Advantage vs Part D
• Uses correct Florida-specific addresses, deadlines, and processes
• References appropriate Medical Coverage Policies for each plan type

Medical Necessity Automation:

• Searches 47,000+ Humana Medical Coverage Policies in seconds
• Extracts exact coverage criteria and cites policy numbers
• Matches clinical notes to MCP requirements automatically

Florida Compliance Built-In:

• Includes Florida Medicaid coverage policies for Healthy Horizons appeals
• Cites Florida patient protection statutes
• References 2026 CMS requirements for Medicare Advantage
• Formats appeals for 7-day expedited processing

Results:

• 5 minutes vs 45-60 minutes manual preparation
• 86% overturn rate vs 67% industry average
• $47,000+ average annual recovery per practice

Independent Florida practices using Muni Appeals reduce denial write-offs by $3,900-$5,200 per month on Humana claims alone.

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Florida State-Specific Escalation Options

If Humana denies your internal appeal, Florida offers additional protection through state agencies and external review.

External Review Process

Who qualifies:

• Internal appeal denied or partially denied
• Humana took too long to decide (30+ days for Medicaid, 7+ days for Medicare)
• Medical emergency situations where waiting for internal appeal would cause harm

How to request:

• For Medicaid: Contact Florida Agency for Health Care Administration (AHCA) at (877) 254-1055
• For Medicare Advantage: CMS will automatically provide external review information after internal denial
• For commercial plans: Call Florida Department of Financial Services at (877) 693-5236

Timeline:

• Standard external review: 60 days
• Expedited external review: 4 business days

Cost:

• $0 (Humana pays for external review)

Decision:

• Binding on Humana (they must comply if you win)
• Reviewed by independent physician not affiliated with Humana

Florida Agency for Health Care Administration (AHCA) Complaints

When to file:

• Humana violated Florida insurance laws
• Denied state-mandated benefits for Medicaid members
• Failed to process appeal within required timelines
• Did not provide required notices or appeal rights

How to file:

• Phone: (888) 419-3456
• Email: consumer.services@myfloridacfo.com
• Online: ahca.myflorida.com/contact-ahca/complaint-faq

What happens:

• AHCA investigates complaint within 30-60 days
• Can require Humana to reverse denial
• May impose fines for regulatory violations

Florida Department of Financial Services Assistance

Consumer hotline: (877) 693-5236 (in-state) or (850) 413-3089 (out-of-state)

What they help with:

• Understanding appeal rights under Florida law
• Filing external review requests
• Mediating disputes between members and Humana
• Investigating potential unfair claims practices

Frequently Asked Questions

How long do I have to appeal a Humana denial in Florida?

Humana Healthy Horizons (Medicaid): 60 calendar days for members, 90 calendar days for providers from the date of denial. Humana Medicare Advantage: 65 calendar days from the date on your Notice of Denial. Part D prescriptions: 65 calendar days from the date on your Notice of Denial of Medicare Prescription Drug Coverage. Missing these deadlines by even one day means automatic rejection with no exceptions.

What is the success rate for Humana appeals in Florida?

Properly documented appeals citing Humana Medical Coverage Policies achieve 72-80% overturn rates. Appeals with peer-to-peer review between treating physician and Humana medical director exceed 85% success rates. Generic appeals without specific MCP citations or clinical documentation average 46% success rates. For Medicare Part C post-acute care denials specifically, peer-to-peer review increases success rates from 46% to 78%.

Does Humana Florida require peer-to-peer review?

Humana doesn't automatically schedule peer-to-peer review—you must request it when submitting your appeal. For Medicaid, call 888-259-6779 and request peer-to-peer. For Medicare Advantage, include peer-to-peer request in your written appeal. Peer-to-peer review allows your treating physician to speak directly with Humana's medical director, which increases overturn rates by 35-40 percentage points, especially for post-acute care denials.

What happens if Humana misses the 7-day Medicare deadline?

Under 2026 CMS regulations (Final Rule CMS-4208-F), if Humana doesn't issue a decision within 7 calendar days for Medicare Advantage appeals, your appeal automatically advances to the Independent Review Entity (IRE) for external review at no cost to you. You don't need to take any action—CMS regulations require automatic escalation. The IRE will make a binding decision within 30 days.

Can I appeal Humana Healthy Horizons denials through Florida Medicaid?

Yes. If Humana Healthy Horizons denies your internal appeal, you can request a Medicaid Fair Hearing through the Florida Agency for Health Care Administration (AHCA). Call (877) 254-1055 to request a fair hearing. You must request the fair hearing within 90 days of Humana's final internal appeal decision. The hearing is conducted by an independent administrative law judge, and the decision is binding on Humana.

What is Humana's Medical Coverage Policy (MCP) and where do I find it?

Humana Medical Coverage Policies (MCPs) are clinical guidelines that define when services are considered medically necessary. You can search all Humana MCPs at mcp.humana.com/tad/tad_new/home.aspx?type=provider. Each MCP includes coverage criteria, clinical evidence requirements, and coding information. Citing specific MCP numbers and criterion-by-criterion explanations increases appeal success rates from 46% to 78-84%.

Does Florida Blue Cross Blue Shield have the same appeal process as Humana?

No. Florida Blue is a completely separate insurance company from Humana with different addresses (P.O. Box 1798, Jacksonville, FL 32231-0014), different timelines (1 year for providers vs 90 days for Humana Medicaid), and different medical policies (Florida Blue MCGs vs Humana MCPs). Never use Florida Blue forms or addresses for Humana appeals.

Can Availity be used for Humana Florida appeals?

Providers only: Yes, if you're a healthcare provider, you can submit appeals through Availity Essentials. Navigate to Claim Status tool, find the denied claim, and select "Dispute Claim." This method works for finalized claims only—not for prior authorization appeals or overpayment disputes. For members, you must use mail, phone, or the online portal at resolutions.humana.com.

What is NaviHealth and how does it affect my appeal?

NaviHealth is an AI-driven utilization management system used by Humana to review post-acute care requests (skilled nursing facilities, inpatient rehabilitation, long-term acute care). According to a 2024 Senate investigation, Humana's post-acute care denial rate increased 54% after implementing NaviHealth. To counter NaviHealth denials, request peer-to-peer review with a Humana physician and provide detailed documentation of ongoing medical necessity.

How do I know if I have Humana Healthy Horizons or Medicare Advantage?

Check your member ID card. Humana Healthy Horizons: Card explicitly says "Humana Healthy Horizons" or "Florida Medicaid" and you qualified based on income/family status. Medicare Advantage: Card says "Humana Gold," "HumanaChoice," or has a Medicare logo and you're 65+ or have a qualifying disability. If unclear, call the number on your card and ask, "What type of plan do I have—Medicaid, Medicare Advantage, or commercial?"

Can I submit a Humana appeal online in Florida?

Yes, for Humana Healthy Horizons (Medicaid): Use resolutions.humana.com/grievances-appeals-forms/member-info. For Medicare Advantage: Online submission varies by plan—check your member portal or call the number on your ID card. For providers: Use Availity Essentials for finalized claims. However, mail submission via certified mail is recommended for proof of timely filing and to ensure all documentation is received.

What if my Humana appeal is denied twice?

After exhausting Humana's internal appeals, you have external review options. Medicaid (Healthy Horizons): Request Medicaid Fair Hearing through Florida AHCA at (877) 254-1055. Medicare Advantage Part C: Your appeal automatically goes to Independent Review Entity (IRE), then if needed to Administrative Law Judge (ALJ). Part D: IRE handles next level, then ALJ if claim value exceeds $200. All external reviews are free and binding on Humana.

Does Humana Florida cover the same services as Humana in other states?

No. Humana Healthy Horizons in Florida must follow Florida Medicaid coverage policies, which differ from Medicaid in other states. Humana Medicare Advantage plans in Florida may use different Local Coverage Determinations (LCDs) than other states depending on the Medicare Administrative Contractor (MAC) jurisdiction. Always reference Florida-specific coverage policies in appeals, not national Humana policies.

What is the 5-day acknowledgment letter requirement?

Florida Medicaid regulations require Humana Healthy Horizons to send you a written acknowledgment letter within 5 business days after receiving your appeal. This letter confirms receipt, provides your appeal ID number, and states the expected decision date. If you don't receive this letter within 5 business days, call 888-259-6779 immediately to confirm your appeal was received and logged correctly.

How does the 2026 CMS Final Rule affect Humana Florida appeals?

The 2026 CMS Final Rule (CMS-4208-F) makes three major changes for Humana Medicare Advantage in Florida: (1) 7-day decision timeline (reduced from 30 days), (2) automatic IRE escalation if Humana misses deadline, and (3) restrictions on reopening previously approved admissions (Humana can only reopen for obvious error or fraud). These changes significantly favor beneficiaries and speed up the appeals process.

Ready to Simplify Your Humana Appeals?

Humana Florida appeals require plan-specific knowledge, tight deadlines (65 days for Medicare, 90 days for Medicaid providers), and detailed Medical Coverage Policy citations. Missing any requirement delays resolution and reduces your success rate from 80% to 46%.

Muni Appeals handles everything automatically:

• ⚡ 5-minute appeal preparation (vs 45-60 minutes manual)
• 📈 86% success rate (vs 67% industry average)
• 💰 $47,000+ average annual revenue recovery
• 🏥 All Humana plan types supported (Healthy Horizons, Medicare Advantage, Part D)
• 🗺️ Florida-specific addresses and processes built-in

Independent practices using Muni Appeals reduce Humana denial write-offs by $3,900-$5,200 per month.

Start 3 Free Appeals

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This guide reflects 2026 Humana appeal procedures and Florida regulations. Humana Healthy Horizons in Florida, Humana Medicare Advantage, and Part D plans have different processes as detailed above. Muni Appeals maintains current procedures for all Humana plan types and Florida-specific state regulations. For questions about appeals for other Florida insurers, see our guides for Aetna Florida appeals and Florida Blue appeals.