Find the documents and forms you need to get the most from your health plan. Contact Member Services at 1-800-448-3810 to request paper copies of forms at no cost. Requested documents will be provided within 5 business days.
Louisiana Medicaid: Documents and forms
Key plan documents
Change of address form
If your home or mailing address changes, you have to let the Louisiana Department of Health (LDH) know. If you don’t, you may lose your coverage or miss out on key health plan information and reminders. After completing the form, you can return it by email or fax.
Louisiana Department of Health Change of Address form – English
Louisiana Department of Health Change of Address form – Spanish
Or, to update your information through us, call us at 1-800-448-3810 (TTY: 711), Monday – Friday, from 7 a.m. – 7 p.m.
Welcome Kit/Quick Start Guide
All new members get a Welcome Kit/Quick Start Guide in the mail. You also can view it below. Your Welcome Kit/Quick Start Guide includes the information you need at the start of your enrollment in Humana Healthy Horizons® in Louisiana.
Behavioral Health-only Welcome Kit/Quick Start Guide – English
Behavioral Health-only Welcome Kit/Quick Start Guide – Spanish
Managed Medical Assistance Welcome Kit/Quick Start Guide – English
Managed Medical Assistance Welcome Kit/Quick Start Guide – Spanish
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Health Needs Assessment
The Health Needs Assessment (HNA) is a set of health questions for you to answer. Your answers will help us make sure you get the care you need. Your Welcome Kit/Quick Start Guide includes an HNA and a postage-paid envelope in which to return it.
Health Needs Assessment (HNA) – English
Health Needs Assessment (HNA) – Spanish
Earn $30 in rewards through Go365 for Humana Healthy Horizons® if you complete your HNA during the first 90 days of enrollment in Humana Healthy Horizons® in Louisiana
Learn more about Go365 for Humana Healthy Horizons
Behavioral health documents and forms
These documents apply to all parishes where Humana Healthy Horizons coverage is available.
Behavioral Health Individual Placement and Support Request Form
Behavioral Health Community Based Outpatient Services Request Form
Behavioral Health Neuropsychological Testing Request Form
Behavioral Health Personal Care Services Request Form
Behavioral Health Peer Support Request Form
Behavioral Health Rehabilitation Request Form
Behavioral Health Crisis Services Treatment Request Form
Behavioral Health Applied Behavioral Health Authorization
Behavioral Health Psychological Testing Authorization Form
Physical health documents and forms
These documents apply to all parishes where Humana Healthy Horizons coverage is available.
Physical Health Authorization Request Form
Physical Health Outpatient Therapy Authorization Request Form
Request for Medicaid EPSDT – Personal Care Services
Request for Prior Authorization – EPSDT Personal Care Services
EPSDT Personal Care Services – Social Assessment Form
EPSDT Personal Care Services – Daily Schedule
EPSDT Personal Care Services – Plan of Care
Member Handbook
Refer to your Member Handbook for information your plan, benefits, and covered services
Member Handbook – English
Member Handbook – Spanish
Provider directories
To find information about in-network doctors, specialists, and healthcare facilities near you:
- Refer to the provider directory in the region where you live, or
- Use our Find Care
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Region 1
Metropolitan: Jefferson, Orleans, Plaquemines and St. Bernard parishes
Provider Directory – English and Spanish (Part 1 of 2)
Provider Directory – English and Spanish (Part 2 of 2)
Region 2
Capital Area: Ascension, East Baton Rouge, East Feliciana, Iberville, Pointe Coupee, West Baton Rouge and West Feliciana parishes
Provider Directory – English and Spanish (Part 1 of 2)
Provider Directory – English and Spanish (Part 2 of 2)
Region 3
South Central: Assumption, Lafourche, St. Charles, St. John the Baptist, St. James, St. Mary and Terrebonne parishes
Provider Directory – English and Spanish
Region 4
Acadiana Area: Acadia, Evangeline, Iberia, Lafayette, St. Landry, St. Martin and Vermillion parishes
Provider Directory – English and Spanish
Region 5
Imperial Calcasieu: Allen, Beauregard, Calcasieu, Cameron and Jefferson Davis parishes
Provider Directory – English and Spanish
Region 6
Central: Avoyelles, Catahoula, Concordia, Grant, LaSalle, Rapides, Vernon and Winn parishes
Provider Directory – English and Spanish
Region 7
Northwest: Bienville, Bossier, Caddo, Claiborne, Desoto, Natchitoches, Red River, Sabine, and Webster parishes
Provider Directory – English and Spanish
Region 8
Northeast Delta: Caldwell, East Carroll, Franklin, Jackson, Lincoln, Madison, Morehouse, Ouachita, Richland, Tensas, Union, and West Carroll parishes
Provider Directory – English and Spanish
Region 9
Florida Parishes: Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington parishes
Provider Directory – English and Spanish
Primary care provider change request form
To change your primary care provider (PCP), use our online PCP change request service in your MyHumana account (desktop version only) or complete and submit the PCP Change Request Form.
Advance directive/Living will
An advance directive, also known as a "living will," is a written legal document that instructs healthcare providers who should make medical decisions on your behalf if you cannot do so. We include below more information about advance directives/living wills:
Pharmacy information and resources
Preferred Drug List
The Louisiana Department of Health (LDH) Preferred Drug List (PDL):
The LDH Single PDL is a list of medicine Louisiana Medicaid recipients can use if prescribed. A Pharmacy and Therapeutics (P&T) Committee recommends medicine to include on or remove from the PDL. Medicine on the PDL is identified as preferred or nonpreferred and includes information about prior authorization requirements.
Please note: The LDH Single PDL is not all-inclusive. Occasionally, your provider may need to get our approval if he or she wants you to use a medicine that is not on our PDL.
Over-the-counter (OTC) catalog and order form
Humana Healthy Horizons in Louisiana members:
- Have a $75/quarter allowance to spend on OTC health and wellness items through the mail
- Can use Humana’s mail-order pharmacy, CenterWell Pharmacy®, which will send medicine to your home
To get started:
- Look up available OTC items in the Humana Health and Wellness Catalog and Order Form
Humana Health and Wellness Catalog and Order Form – English
Humana Health and Wellness Catalog and Order Form – Spanish
- Write down your order on the Order Form
- Submit your order:
- By mail:
CenterWell Pharmacy
P.O. Box 1197
Cincinnati, OH 45201-1197 - By phone:
Call CenterWell Pharmacy at 1-855-211-8370 (TTY: 711). Customer Care Representatives are available Monday – Friday, 7 a.m. – 10 p.m. and Saturday, 7 a.m. – 5:30 p.m. - By fax: 1-800-379-7617
- By mail:
Call the number on the back of your ID card if you have questions about your benefit.
Health benefits claim form
Health benefits claim form
To request reimbursement of out-of-pocket expenses tied to a Humana Healthy Horizons in Louisiana covered benefit, please complete and return a Health Benefits Claim Form.
Health Benefits Claim Form
Expanded Benefits Reimbursement Form
We hope you don’t have to pay out of pocket for the benefits you get as a Humana Healthy Horizons in Louisiana member. If you do, let us know by filling out a reimbursement claim form, and you may get a refund.
Fill out the form below to send a reimbursement claim.
Grievances and appeals forms
We want you to be happy with the care you get. We hope you get the best care possible.
If you are not happy with any part of your healthcare plan, Member Services, your doctor, or a facility, you can send in a grievance.
You also can appeal a claim or a denied service using the grievances and appeals forms.
To have someone send an appeal or grievance for a covered member, we must have a completed Appointment of Representative Form
Learn more about grievances and appeals
Legal and privacy notices
The legal and privacy notices below provide information about:
- How Humana uses, and when we might share, your personal information
- Your privacy rights
Individual privacy rights – English
Individual privacy rights – Spanish
Rights and responsibilities – English
Rights and responsibilities – Spanish
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Notice – English
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Notice – Spanish
HIPAA Privacy Complaint Form
Notice of Non-Discrimination
Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate or exclude people because of their race, color, religion, gender, gender identity, sex, sexual orientation, age, disability, national origin, military status, veteran status, genetic information, ancestry, ethnicity, marital status, language, health status, or need for health services.
Non-Discrimination Notice – English
Non-Discrimination Notice – Spanish
Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
Humana Inc. and its subsidiaries comply with Section 1557 by providing free auxiliary aids and services to people with disabilities when auxiliary aids and services are necessary to ensure an equal opportunity to participate.
Auxiliary Aids and Services Notice – English
Auxiliary Aids and Services Notice – Spanish
Detecting, preventing, and reporting healthcare fraud
As part of our efforts to improve the healthcare system, we are committed to:
- Detecting, correcting, and preventing healthcare fraud
- Educating our members about how to detect and/or prevent fraud
Performance measurement
Performance measurement
Refer to the below information to see:
- How we’re measured as a health plan and
- How we’re doing
Guide to Healthcare Effectiveness Data and Information Set (HEDIS®) measurements
State of Health Care Quality Report (NCQA)
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