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
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.
Medicare Advantage and Prescription Drug Plan
Disenrollment Instructions and Form
Medicare Prescription Drug Claim Form
Return completed forms by mail, fax or the
Declaration of Prior Prescription Drug Coverage Form
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.
Downloadable request forms for Part D prior authorization
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
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.
Appointment of representative form for appeals and grievances
If you are 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 are authorized to work with Humana on his or her behalf.
You also can get the AOR form on the
Power of Attorney (POA)
You have 2 ways to submit a Power of Attorney form to Humana:
1.) Submit a
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
- 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
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
Member blocking request
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
- 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 Vision and Humana Vision PLUS claim form
For members seeking a reimbursement after visiting an out-of-network provider.
Group Pre-enrollment Disclosure Guides
Michelle’s Law
Process for continued coverage for full-time students on a medical leave of absence.
Group life claim forms
Group disability income claim forms
Group disability income state notices
Group Pre-enrollment Disclosure Guides
View state-specific documents and resources related to Humana’s offerings in your state.
Medical Forms
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:
You can file an appeal through the Exceptions and appeals –