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
Medicare Advantage 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.
Use this form for medical services received in the United States:
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
Limited Income Newly Eligible Transition (NET) pharmacy claim 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
Medicare Advantage 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
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 Appointment of Representative 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.
Notice of nondiscrimination
Please
Multi-language translator service
View
Member blocking request
State-specific documents
View state-specific documents related to Humana’s offerings in your state.
Dental forms
Humana doesn't require a specific dental claim form. Your dentist will submit your claim directly to Humana. However, if you need to submit a dental claim for reimbursement, there are 2 ways to do so:
- Itemized statement from a dentist
Send a copy of the itemized statement to the address on the back of your Humana dental ID card. Make sure the itemized statement includes the patient's name and the Humana member's ID number. Please keep a copy for your records. - Dentist’s claim form
If using adental benefits claim form , please mail the completed form to the following address:
Humana
P.O. Box 14283
Lexington, KY 40512-4283
Grievance and Appeals Request Form
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.
Michelle's Law
Process for continued coverage for full-time students who are on medical leave.
Member blocking request
Disable the secure member website for yourself or a family member.
Privacy
View Humana's privacy rights and download forms. You can also learn more about your rights on the
Multi-language translator service
Medical forms
For employer plans with group effective date of 9/1/2023 or later
For employer plans with group effective date prior to 9/1/2023
Dental benefit claim form
Pharmacy forms
Both forms below must be completed, signed and returned to Humana for processing. Return completed forms by mail, fax or the
The No Surprises Act and Transparency in Coverage Rule
The No Surprises Act and Transparency in Coverage (TiC) Rule, effective Jan. 1, 2022 and July 1, 2022 respectively, includes key provisions that provide protections, accessibility and clearer communications for members. The plan and issuer Transparency in Coverage link below includes machine-readable files to meet the requirement for plans and issuers to publish their negotiated payment rates for in-network providers and their allowed amounts for out-of-network claims. The frequently asked questions (FAQ) provide an overview of key provisions and questions to help employers stay updated on the ongoing changes. As the requirements and actions to achieve these changes continue to evolve, we will continue to provide updated information as quickly as possible.
Contraceptive Benefits Plan Form
This form applies ONLY to members who received a letter from Humana directing them to the Humana Contraceptive Benefits Plan SPD link. If you are not sure whether this applies to you, please call the customer service phone number on the back of your Humana ID card.
Commercial Reproductive Health Coverage FAQ
Read more about our coverage and other frequently asked questions.
Behavioral Healthcare Services
The
Grievance and Appeals Request Form
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.
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 one of the following:
(Medical)
Humana Correspondence
P.O. Box 14601
Lexington, KY 40512
Fax: 1-800-633-8188
(Specialty Benefits)
Humana Specialty Benefits
P.O. Box 14611
Lexington, KY 40512-4611
Fax: 1-888-556-2128
(CompBenefits)
Humana/CompBenefits
100 Mansell Court East, Suite 400
Roswell, GA 30076
Fax: 1-678-808-3712
Spending account forms
CenterWell Pharmacy™ mail delivery
Life claim forms
Group disability claim forms
Group disability state notices
Prior carrier deductible credit form
For new members apply current year expenses to Humana deductible.
Michelle's Law
Process for continued coverage for full-time students who are on medical leave.
Member blocking request
Disable the secure member website for yourself or a family member.
Privacy
View Humana's privacy rights and download forms. You can also learn more about your rights on the
Multi-language translator service
State-specific documents and resources
View state-specific documents and resources related to Humana’s offerings in your state.
Georgia Treatment Cost Calculator
This Treatment Cost Calculator is meant to assist members of the public in determining approximate treatment costs based on preloaded commercial benefit plan information. The tool is based on Humana commercial plans available within the state of Georgia.
This communication provides a general description of certain identified insurance or non-insurance benefits provided under 1 or more of our health benefit plans. Our health benefit plans have exclusions and limitations and terms under which the coverage may be continued in force or discontinued. For costs and complete details of the coverage, refer to the plan document or call or write your Humana insurance agent or the company. In the event of any disagreement between this communication and the plan document, the plan document will control.
Pre-enrollment disclosure forms
Review a description of plan provisions which may exclude, limit, reduce, modify or terminate your group health insurance coverage.
Tax documents
Learn more about Form 1095-B and how to request a copy.
Humana Vision and Humana Vision PLUS claim form
For members seeking a reimbursement after visiting an out-of-network provider.