Whether you're a Humana Medicare member or you get insurance from your employer, you have easy access to documents and forms. Choose the category that best describes your coverage.
Documents and Forms
Humana members
Medical Claim Forms
Sometimes when you get medical care, you may pay the full cost up front and then need to ask Humana to pay you back. To make sure you are giving us all the information we need to process your reimbursement request, complete 1 of the forms below.
We require the following data to make a decision: your name and the member ID from your Humana ID card, an itemized statement from the provider showing the services provided with the date(s) of service for those services, and your receipt or other proof of your payment. We also need the revenue code(s), if applicable; relevant CPT and HCPCS code(s); diagnosis code(s); and the place of treatment. Those may be included on the provider’s itemized statement, but you will need to provide them if they are not.
For medical services received in the United States, please mail a completed Health Benefits Claim Form
Humana
P.O. Box 14611
Lexington, KY 40512-4611
Use 1 of these forms for medical services received outside the United States. Note: medical records must be submitted when requesting reimbursement for medical services received outside the United States. An itemized statement from the provider is not required. Also, revenue codes, CPT and HCPCS codes, and diagnosis codes might not be available for services outside the United States. In such cases, include a description of each medical service provided and a description of the reason for the visit.
International Health Benefits Claim Form – English
International Health Benefits Claim Form – Spanish
Medicare Advantage and Prescription Drug Plan
Disenrollment Instructions and Form
Prescription Drug Claim Form
Return completed forms by mail, fax or the PromptPA portal
Medicare Prescription Drug Claim Form for Member Reimbursement – English
Medicare Prescription Drug Claim Form for Member Reimbursement – Spanish
Commercial Prescription Drug Claim Form – English
Commercial Prescription Drug Claim Form – Spanish
Declaration of Prior Prescription Drug Coverage Form
Declaration of Prior Prescription Drug Coverage – English
Declaration of Prior Prescription Drug Coverage – Spanish
Medicare Part D drug coverage determination
There may be times when it is necessary to get approval from Humana before getting a prescription filled. This is called “prior authorization” or Part D coverage determination.
Online request for Part D drug prior authorization
Downloadable request forms for Part D prior authorization
Request for Medicare Prescription Drug Coverage Determination Form – English
Request for Medicare Prescription Drug Coverage Determination Form – Spanish
Learn more about the Part D drug prior authorization process
Grievance, appeal and coverage redetermination
If you have a complaint related to your Humana Part C/Medicare Advantage plan, Part D drug coverage or any aspect of a member's care, we want to hear about it and see how we can help.
You can use this form to:
- File an appeal for a denied medical service, a medical device or a denied prescription medication.
- Submit a grievance about your complaint and tell us how you are dissatisfied with your experience.
Please complete the form below and a licensed Humana sales agent will reach out to help address your issue.
Downloadable request forms for grievance, appeal and coverage redetermination
Appeal, Complaint or Grievance Form – English
Appeal, Complaint or Grievance Form – Spanish
Appeal, Complaint or Grievance Form – Chinese
Learn more about the Medicare drug (Part D) Coverage Redetermination Process
Learn more about the Medicare Advantage (Part C) Coverage Reconsideration Process
Grievances and Appeals/Inquiry Directory
Waiver of Liability
A non-contract provider, on his or her own behalf, may request a reconsideration for a denied claim only if the non-contract provider completes a Waiver of Liability statement, which states that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal.
Waiver of Liability Form
Appointment of Representative form for appeals and grievances
If you’re filing an appeal or grievance on behalf of a member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you’re authorized to work with Humana on his or her behalf.
Appointment of Representative Form – English
Appointment of Representative Form – Spanish
You also can get the AOR form on the Centers for Medicare & Medicaid Services website
Power of Attorney (POA)
You have 2 ways to submit a Power of Attorney form to Humana:
1.) Submit a Power of Attorney form online .
2.) Mail your Power of Attorney form to:
Humana Correspondence
Attention: Power of Attorney
P.O. Box 14168
Lexington, KY 40512-4168
Report an injury or get information about an injury investigation
Use the Injury Report and File Status Request
- Report accidents
- Confirm if Humana provides benefits for an accident-related injury or illness
- Request final payment information needed to settle claims made against other insurance carriers and individuals
Once you have completed the request, please email a saved copy to SubrogationReferrals@Humana.com , or mail to:
Humana Subrogation and Other payer Liability
004/48120
P.O. Box 2257
Louisville, KY 40201-2257
If you have additional questions or need to supply additional information, please contact us.
CenterWell Pharmacy™ mail delivery forms
CenterWell Pharmacy Registration and Order Form – English
CenterWell Pharmacy Registration and Order Form – Spanish
Physician Fax Form – English
Physician Fax Form – Spanish
Member blocking request
Disable access
Dental claim forms
Humana doesn't require a specific dental claim form. Your dentist will submit your dental claim directly to Humana. However, an out-of-network dentist may require you to pay up front and you will need to submit a claim to Humana for reimbursement.
For out-of-network claims, you can submit a dental benefits claim form
- Itemized statement from your dentist with American Dental Association (ADA) codes
- Patient’s name and Humana member ID number
- Dentist’s full name, address and tax ID
Please make sure your submission is clear and legible, and that you keep a copy for your records. Out-of-network dental claims normally process within 30 days unless it is for one of the following services: oral evaluations, periodontal scaling, fillings, crowns, implants, root canals, oral surgery or crowns, which may require additional documentation from the dentist.
You can get additional information on out-of-network claims reimbursement on Humana.com/sb
Humana Vision and Humana Vision PLUS claim form
For members seeking a reimbursement after visiting an out-of-network provider.
Out-of-network vision services claim form
Spanish out-of-network vision services claim form
Group Pre-enrollment Disclosure Guides
Dental and Vision Regulatory Pre-enrollment Disclosure Guide
Michelle’s Law
Process for continued coverage for full-time students on a medical leave of absence.
Michelle’s Law – H.R. 2851
Appointment of Representative form for appeals and grievances
If you’re filing an appeal or grievance on behalf of a Humana plan member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you’re authorized to work with Humana on his or her behalf.
Appointment of Representative Form – English
Group life claim forms
Accelerated Benefits Claim Form - English
Group Life Claim Form – English
Group Life Claim Form – Spanish
Dismemberment Benefits Claim Form - English
Waiver of Premium Claim Form – Employee Statement
Continuing Waiver of Premium Claim Form – Employee Statement
Humana Life Beneficiary Designation - English
Life Authorization Form
Group disability income claim forms
Application for short term disability income benefits – English
Application for short term disability income benefits – Spanish
Application for long term disability income benefits
Application for long term disability income benefits – Spanish
Humana Short-Term Income Protection – Claim Form
Continuing Short Term Disability Claim Form
Group disability income state notices
Group Long Term Disability State Notices
Group Short Term Disability State Notices
Group Pre-enrollment Disclosure Guides
Disability Income Regulatory Pre-enrollment Disclosure Guide
Life Regulatory Pre-enrollment Disclosure Guide
View state-specific documents and resources related to Humana’s offerings in your state.
Medical Forms
New York Medicare Supplement Narrative Summaries
Arizona exceptions and appeals
If you have an individual plan or a fully insured group plan (through your employer) for medical, dental, or vision benefits, you can appeal our decision for denied claims or services. For a detailed explanation of the appeal process, review the Health Care Appeals Information Packet available in these links:
Arizona Medical Appeals Packet – English version
Arizona Medical Appeals Packet – Spanish version
Arizona Dental and Vision Appeals Packet – English version
Arizona Dental and Vision Appeals Packet – Spanish version
You can file an appeal through the Exceptions and appeals – Insurance through an employer page . Select the appeal you’d like to make and follow the instructions on that page.
Group Dental handbooks
Texas - DHMO Handbook HD 405
Texas - DHMO Handbook HD 410
Texas - DHMO Handbook HD 415
Texas - DHMO Handbook HS 405
Note: Our forms are in Portable Document Format (PDF) and require Adobe Reader for viewing and printing. To get the plug-in, visit Adobe's Website to