Healthcare policy rules explained in plain language

We created this guide to help you better understand some of the terms and provisions that might appear in your Humana insurance policy.

Certain rules vary by state.

Medical and Dental plan provisions

Out of Network Liability and Balance Billing

HMOx

If you have a Humana HMOx plan, and you visit an out-of-network doctor or hospital (aka. “provider”) for services and treatment, you will be responsible for any charges above the plan’s maximum allowable fee.

There are exceptions to this rule that may apply if you live in AZ, FL, IL, MO, TN or NV.

If you have questions about how the maximum allowable fee applies in your state, please call the number on your Humana Member ID card.

Please note: Any amount you pay the provider above the maximum allowable fee will not apply to your out-of-pocket limit or deductible.

You can find a doctor who’s in your network here: Find a doctor

A network is a group of healthcare providers who have agreed to accept a set rate for specific services when members of a health plan use their benefits. Providers within the network for a specific plan are also called “participating providers.” Your network choices may vary, depending on your plan and where you live.

This is the maximum amount Humana will pay a healthcare provider for a particular service or set of services.

HMOx – CO, OH, TX

If you live in Colorado, Ohio, or Texas and have a Humana HMOx plan, when you visit an out-of-network doctor or hospital (aka. “provider”) for emergency treatment of a life-threatening illness or injury, you do not have to pay for charges that exceed the plan’s maximum allowable fee.

For non-emergency services and treatment, you may be responsible for charges that exceed the maximum allowable fee. See your plans Explanation of Benefits (EOB) for details.

You can find a doctor who’s in your network here: Find a doctor

A network is a group of healthcare providers who have agreed to accept a set rate for specific services when members of a health plan use their benefits. Providers within the network for a specific plan are also called “participating providers.” Your network choices may vary, depending on your plan and where you live.

This is the maximum amount Humana will pay a doctor or hospital for a particular service or set of services.

PPOx

If you have a Humana PPOx plan and you visit an out-of-network doctor or hospital (aka. “provider”) for treatment, you will be responsible for any charges that exceed the plan’s maximum allowable fee.

Please note: Any amount you pay the provider above the maximum allowable fee will not apply to your out-of-pocket limit or deductible.

You can find a doctor who’s in your network here: Find a doctor

A network is a group of healthcare providers who have agreed to accept a set rate for specific services when members of a health plan use their benefits. Providers within the network for a specific plan are also called “participating providers.” Your network choices may vary, depending on your plan and where you live.

This is the maximum amount Humana will pay a doctor or hospital for a particular service or set of services.

Dental

If you have a Humana dental plan and you visit an out-of-network dentist, you will be responsible for any charges that exceed the plan’s maximum allowable fee.

You can find a dentist who’s in your network here: Find a dentist

A network is a group of healthcare providers who have agreed to accept a set rate for specific services when members of a health plan use their benefits. Providers within the network for a specific plan are also called “participating providers.” Your network choices may vary, depending on your plan and where you live.

This is the maximum amount Humana will pay a dentist for a particular service or set of services.

Grace Period and Claims Pending

Medical + Dental

The amount you pay each month toward your health plan is called a “premium.” Premium payments are due on the first day of the month.

If you are eligible for the federal healthcare premium tax credit and we don’t receive your monthly premium payment by the due date, your plan’s grace period will begin on the first of that month and last 90 days.

We will pay all appropriate claims for services rendered during the first month of the grace period for members receiving the federal healthcare premium tax credit and may pend claims for services rendered to the enrollee in the second and third months of the grace period.

A claim that has been received but processing is not complete is considered a pended claim.

If you are not eligible for the federal healthcare premium tax credit and we don’t receive your monthly premium payment on time, your plan’s grace period will begin on the first day of that month and last 31 days.

Whether your plan’s grace period is 31 or 90 days, your coverage will end on the last day of the month when your last premium was paid. (For example, if your May premium is not paid on or before May 1st, we will only cover claims made through the end of April.)

If we pay for claims you made during a grace period, we will seek to recover the payment(s).

We will seek to recover the cost of any payment we made toward your claims if:

  • We overpaid
  • We paid for claims made during a grace period, but never received the overdue premium payment
  • The claim was fraudulent

Medical - GA

In Georgia, if you get insurance through your employer and you or a family member on your plan is completely disabled when coverage ends, we will extend limited coverage as described in the Extension of Benefits section of your certificate/policy.

Note: This only applies if you get insurance through your employer. HumanaOne plans do not have Extension of Benefits exceptions.

Register or Sign in to MyHumana to view your certificate/policy

Register or Sign in to MyHumana to see an online copy of your certificate/policy, as well as manage your benefits, view your plan information, and get the most from your Humana health plan.

We will seek to recover the cost of any payment we made toward your claims if:

  • We overpaid
  • We paid for claims made during a grace period, but never received the overdue premium payment
  • The claim was fraudulent

Claims Submission

Medical

In most cases, your doctor or hospital will submit insurance claims for healthcare services on your behalf.

If you are asked to file a claim yourself, please follow the links below, download the Health Benefits Claim Form, and follow the instructions in the form.

Please include the following information when submitting the claim.

  • Name and address for either you or the person in your family who received the service(s)
  • Name and address of the doctor or hospital that provided the service
  • Procedure or nature of the treatment
  • Date of the service
  • Billed amount

If you have an individual plan (not through your employer) download the correct forms from Humana.com/individual-and-family-support/tools/member-forms/ and submit to:

Humana Claims

P.O. Box 14635

Lexington, KY 40512-4635

Customer Care: 1-800-833-6917

If you get insurance through your employer, go to: Humana.com/insurance-through-employer-support/tools/member-forms and submit to:

Humana Claims

P.O. Box 14601

Lexington, KY 40512-4601

Customer Care: 1-800-448-6262

All claims must be submitted within a limited time after you receive a healthcare service. Normally this ranges from 90 days to 15 months from the date of service, but may vary.

See your plan’s Proof of Loss period for the specific timeframe.

Register or Sign in to MyHumana to view your certificate/policy

Register or Sign in to MyHumana to see an online copy of your certificate/policy, as well as manage your benefits, view your plan information, and get the most from your Humana health plan.

Dental

In most cases, your dentist will submit insurance claims for dental services to us on your behalf.

If you are asked to file a claim yourself, please submit your itemized statement to the address on the back of your Humana Member ID card

Before you send us your claim, please ensure the following information is included:

  • Name of the patient
  • Date of the service
  • Amount you were billed
  • Description of the services provided
  • Your Humana Member ID number

Dental Claims Mailing Address and Phone Number:

Humana Dental Claims

P.O. Box 14611

Lexington, KY 40512-4611

Customer Care: 1-800-558-2813

All claims must be submitted within 90 days to 15 months after you receive a healthcare service. See your plan’s Proof of Loss period for details on the specific timeframe.

Register or Sign in to MyHumana to view your certificate/policy

Register with MyHumana to manage your benefits online, view your plan information and policies, and get the most from your Humana health plan.

Recovery of Premium Overpayment

Medical + Dental

If you have individual insurance (not through an employer) and overpaid for your monthly premium, we will apply the amount you overpaid as a credit toward your next premium bill. To request the overpayment as a refund, you may call the number on the back of your Humana Member ID card.

When you no longer have Humana benefits but overpaid on a previous bill, we will automatically refund the premium within 10 business days if the payment was under $500. If the amount is over $500, the turn-around time will be longer.

If you get insurance through your employer, and believe you’ve overpaid the premium and are due a refund, please contact your company’s health benefits administrator.

Pre authorization + Medical necessity

Medical

For certain specialized healthcare services and medicines, we will review the request ahead of time to determine if the cost is covered, or if a more cost-effective alternative is available. This process is called “preauthorization” (also called “prior authorization” or “predetermination of benefits”).

We will grant a preauthorization when we are able to determine that the service is both medically necessary and covered by the terms of your medical plan. If the preauthorization is not granted, your provider may suggest an alternative procedure or medication that is covered.

Please note: With limited exceptions, preauthorization must be granted before the service is provided. It will remain valid for up to 90 days after the review, and is not a guarantee of what we will pay toward the treatment.

A professional health service will be “medically necessary” if it meets (at minimum) the following conditions:

  • In accordance with nationally recognized standards of medical practice;
  • Clinically appropriate;
  • Not primarily for the convenience of the patient or provider; and
  • Not more costly than an alternative service
  • Performed in the least costly site

Dental

If you expect to pay more than $300 for dental care, your dentist may submit a proposed dental treatment plan that we will use to determine if your dental benefits cover the treatment.

This is known as a “predetermination of benefits” (also called “prior authorization”)

The dental treatment plan may include:

  • A list of services to be performed, including any supporting documentation
  • A written description from the dentist of the treatment
  • An itemized list of costs

Please note: With limited exceptions, predetermination of benefits must be granted before the service is provided. It will remain valid for up to 90 days after the review, and is not a guarantee of what we will pay toward the treatment.

Retroactive Denials

Medical + Dental

Under certain circumstances, we may deny a claim after the provider was already paid. This is called “retroactive denial,” and may occur if (among other reasons):

  • Your plan ended, but you received services before the provider was notified.
  • You received services before you paid your first month’s premium payment and never paid the overdue premium, so your plan never went into effect.
  • The claim was found to be fraudulent.
  • Information submitted to us by your provider was incorrect.
  • Payment was made for a duplicate claim.
  • Due to Coordination of Benefits provisions.
  • You have other insurance coverage that paid benefits toward the claim.

In cases of fraud, there is no time limit for a retroactive claim denial.

For non-fraud cases, the time limit is typically twelve (12) months from the time the claim was made, but can vary by state.

If we retroactively deny your claim, for any reason, we will notify you via mail, email or your preferred contact method with an explanation.

In certain cases, we may seek repayment from the doctor or hospital for a retroactively denied claim. If that happens, they may be able to bill you for the cost of the denied claim.

To avoid retroactive denial of a claim, you should:

  • Make sure that your premiums are paid on time.
  • Review your provider’s billing statement to ensure that the services you received are true and accurate.

If you have another health insurance plan in addition to your Humana benefits, we may adjust your benefits so that the amount we pay toward a claim will not exceed 100% of the provider’s charge. We refer to this rule as Coordination of Benefits (COB).

Medical - FL & GA

For non-fraud cases in Florida, we may retroactively deny a claim up to thirty (30) months after it was paid.

In non-fraud cases in Georgia, we may retroactively deny a claim up to twelve (12) months after it was paid, depending on the type of claim.

If you have another health insurance plan in addition to your Humana benefits, we may adjust your benefits so that the amount we pay toward a claim will not exceed 100% of the provider’s charge. We refer to this rule as Coordination of Benefits (COB).

Explanations of Benefits (EOB)

Medical + Dental

Your plan’s Explanation of Benefits (EOB) is an easy-to-read summary of any claims that were paid on your behalf. It also provides a snapshot of any year-to-date expenses we applied to your plan.

Your EOBs will be provided via mail or electronically, depending on your preference.

Coordination of Benefits (COB)

Medical + Dental

If you have more than one health insurance plan, we may adjust your benefits so that the amount we pay toward a claim will not exceed 100% of the provider’s charge. We refer to this rule as Coordination of Benefits (COB).

Pharmacy plan provisions

Out of Network Liability + Claims Submission

As a Humana member, you can save on your prescription drug costs through a nationwide network of pharmacies. To find a Humana network pharmacy near you, please visit Humana.com/PharmacyLocator.

In addition to obtaining medicines from retail pharmacies, you may obtain up to a 90-day supply of covered medicines* mailed directly to your home (or another address you designate) from a mail order pharmacy such as Humana Pharmacy®.

Learn more about our mail-order pharmacy service at
Humana.com/pharmacy/humana-pharmacy/

*Specialty drugs (and opioids in certain states) are limited to a 30-day supply.

Frequently Asked Questions

Quantity Limits

Quantity limits are the maximum amount of a medicine your plan will cover for one copayment or over a certain number of days. For example, you may fill no more than 60 pills in a 30-day period.

Learn more about Quantity Limits

Prior Authorization

Certain medicines require prior authorization before your plan can provide coverage. We will grant (or decline) prior authrozation when the review determines that the prescription is considered medically necessary, per the terms and provisions of your plan.

Learn more about Prior Authorization

Step Therapy

Step therapy is a process where you must try a generic or a lower-cost brand-name medicine, before your plan will cover the higher-priced brand name or generic medicine.

Learn more about Step Therapy

Prior Authorization / Drug Exceptions

If your doctor wants to prescribe you a drug that is not included on our approved drug list, you, your appointed representative, or your prescribing doctor can request a standard or expedited exception for that drug.

A standard exception request for coverage of a clinically appropriate drug not included on our approved drug list may be initiated by you, your appointed representative, or the prescribing doctor by calling the customer service number on your identification card, in writing, or electronically by visiting our Website at www.humana.com. We will respond to a standard exception request no later than 72 hours after the receipt date of the request.

An expedited exception request for coverage of a clinically appropriate drug not included on our approved drug list based on exigent circumstances may be initiated by you, your appointed representative, or your prescribing doctor by calling the customer service number on your identification card, in writing, or electronically by visiting our Website at www.humana.com. We will respond to an expedited exception request within 24 hours of receipt of the request.

If we deny a standard or expedited exception request to cover a drug not included on our approved drug list, you, your appointed representative, or your prescribing doctor have the right to appeal our decision to an external independent review organization. The exception request decision letter will provide additional instructions to appeal our decision or you can call the customer service number on your identification card.

Here are contacts your doctor can use:

  • Call 1-800-555-CLIN (2546): 8 a.m. to 8 p.m., Monday - Friday.

Use fax or mail: Your prescribing doctor can go to Humana.com and complete the appropriate form. You may also need a statement of medical necessity, possibly including specific patient medical information as well as peer-reviewed literature related to the request.

Fax number: 1-877-486-2621

Mailing address:
Humana Pharmacy Operations
P.O. Box 33008
Louisville, KY 40232-3008

Contact us

If you have an individual plan (not through your employer), call 1-800-833-6917 (TTY: 711) Monday – Thursday 7 a.m. – 7 p.m. CST or Friday 7 a.m. – 6 p.m. CST.

If you’re covered through your employer, call 1-800-448-6262 (TTY: 711) Monday – Friday 8 a.m. – 6 p.m. EST