Humana members

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.

Medicare Individual and family Through your employer

Health benefits claim form , PDF opens new window

International health benefits claim form - English , PDF opens new window

International health benefits claim form - Spanish , PDF opens new window

Medicare Advantage and Prescription Drug Plan Disenrollment Instructions and Form

Form to Request to End Plan (Disenroll) and Special Election Questionnaire - English , PDF opens new window

Form to Request to End Plan (Disenroll) and Special Election Questionnaire - Spanish , PDF opens new window


Medicare Prescription Drug Claim Form

Medicare Prescription Drug Claim Form for Member Reimbursement - English , PDF opens new window

Medicare Prescription Drug Claim Form for Member Reimbursement - Spanish , PDF opens new window


Declaration of Prior Prescription Drug Coverage Form

Declaration of prior prescription drug coverage - English , PDF opens new window

Declaration of prior prescription drug coverage - Spanish , PDF opens new window


Limited Income Newly Eligible Transition (NET) pharmacy claim form

Prescription drug claim form for member reimbursement - English , PDF opens new window

Prescription drug claim form for member reimbursement - Spanish , PDF opens new window


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 , opens new window

Downloadable request forms for Part D prior authorization

Request for Medicare Prescription Drug Coverage Determination form - English , PDF opens new window

Request for Medicare Prescription Drug Coverage Determination form - Spanish , PDF opens new window

Learn more about the Part D drug prior authorization process


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 the following to the address on the back of your Humana ID card:

  • 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


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 , PDF opens new window

Appeal, complaint, or grievance form - Spanish , PDF opens new window

Learn more about the Medicare drug (Part D) coverage redetermination process

Learn more about the Medicare Advantage (Part C) reconsideration process


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, PDF opens new window


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.

Appointment of representative form - English , PDF opens new window

Appointment of representative form - Spanish , PDF opens new window

You also can get the Appointment of Representative form on the Centers for Medicare & Medicaid Services website , opens new window.


Report an injury or get information about an injury investigation

Use the Injury Report and File Status Request , PDF opens new window to:

  • 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.


Notice of nondiscrimination

Please visit our accessibility page for information on filing a discrimination complaint


Multi-language translator service

View multi-language interpreter services contact information


Member blocking request

Disable access , PDF opens new window to your secure member website for yourself or a family member


State-specific documents

View state-specific documents related to Humana’s offerings in your state.

New York Medicare Supplement Narrative Summaries , PDF opens new window

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:

  1. 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.
  2. Dentist’s claim form
    If using a dentist's 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

Grievance/appeal request form - English , PDF opens new window

Grievance/appeal request form - Spanish , PDF opens new window


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.

Appointment of authorized representative form - English , PDF opens new window

Appointment of authorized representative form - Spanish , PDF opens new window


Michelle's Law

Process for continued coverage for full-time students who are on medical leave.

Michelle’s Law – H.R. “2851” , PDF opens new window


Member blocking request

Disable the secure member website for yourself or a family member.

Website blocking request , PDF opens new window


Privacy

View Humana's privacy rights and download forms. You can also learn more about your rights on the Rights and responsibilities page.

Consent for release of protected health information – English , PDF opens new window

Consent for release of protected health information – Spanish , PDF opens new window

Revocation of consent for release of protected health information – English , PDF opens new window

Revocation of consent for release of protected health information – Spanish , PDF opens new window


Multi-language translator service

Multi-language interpreter services contact information

Medical forms

At-home Over-the-counter (OTC) COVID Test Reimbursement Form , PDF opens new window

Puerto Rico Commercial Members Reimbursement Form “Over-the-Counter” COVID-19 Home Tests – English , PDF opens new window

Puerto Rico Commercial Members Reimbursement Form “Over-the-Counter” COVID-19 Home Tests – Spanish , PDF opens new window

Health benefits claim form - English , PDF opens new window

Health benefits claim form - Spanish , PDF opens new window

International health benefits claim form - English , PDF opens new window

International health benefits claim form - Spanish , PDF opens new window


Pharmacy forms

Both forms below must be completed, signed and returned to Humana for processing.

Prescription drug claim form - English , PDF opens new window

Prescription drug claim form - Spanish , PDF opens new window

Limited income NET Pharmacy drug claim form - English , PDF opens new window

Limited income NET Pharmacy drug claim form - Spanish , PDF opens new window


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.

Plan and Issuer Price Transparency

No Surprises Act and TiC FAQ , PDF opens new window


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.

SPD for the Contraceptive Benefits Plan , PDF opens new window


Commercial Contraceptive Coverage FAQ

Humana follows the Health Resources and Services Administration (HRSA)-supported Women’s Preventive Services Guidelines which recommends that adolescent and adult women have access to the full range of contraceptives and contraceptive care to prevent unintended pregnancies and improve birth outcomes. Read more about our contraception coverage and other frequently asked questions.

Commercial Contraceptive Coverage FAQ , PDF opens new window


Behavioral Healthcare Services

The Federal Mental Health Parity and Addiction Equity Act describes federal and state requirements for Behavioral Healthcare Services and includes contact information for the Department of Financial Services for inquiries or complaints.

Florida residents can view the Behavioral Health Overview


Grievance and Appeals Request Form

Grievance/appeals request form - English , PDF opens new window

Grievance/appeals request form - Spanish , PDF opens new window


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.

Appointment of representative form - English , PDF opens new window

Appointment of representative form - Spanish , PDF opens new window


Spending account forms

Humana access spending account reimbursement claim form - English , PDF opens new window

Direct deposit request - English , PDF opens new window

HSA beneficiary designation , PDF opens new window

HSA account closure , PDF opens new window

Letter of medical necessity - English , PDF opens new window


CenterWell Pharmacy™ mail delivery

CenterWell Pharmacy registration and order form - English , PDF opens new window

CenterWell Pharmacy registration and order form - Spanish , PDF opens new window

Physician fax form – English , PDF opens new window

Physician fax form – Spanish , PDF opens new window


Life claim forms

Accelerated benefits claim form - English , PDF opens new window

Group life claim form –English , PDF opens new window

Group life claim form –Spanish , PDF opens new window

Dismemberment benefits claim form - English , PDF opens new window

Waiver of premium initial claim form – English , PDF opens new window

Waiver of premium continuation claim form – English , PDF opens new window

HumanaLife Beneficiary Designation – English , PDF opens new window

Life authorization form , PDF opens new window


Group disability claim forms

Humana short term income Protection claim form , PDF opens new window

Continuing short term disability claim form , PDF opens new window


Prior carrier deductible credit form

For new members apply current year expenses to Humana deductible.

Prior carrier deductible credit form – English , PDF opens new window


Michelle's Law

Process for continued coverage for full-time students who are on medical leave.

Michelle’s Law – H.R. “2851” , PDF opens new window


Member blocking request

Disable the secure member website for yourself or a family member.

Website blocking , PDF opens new window


Privacy

View Humana's privacy rights and download forms. You can also learn more about your rights on the Individual Privacy Rights page.

Consent for release of protected health information – English , PDF opens new window

Consent for release of protected health information – Spanish , PDF opens new window

Revocation of consent for release of protected health information – English , PDF opens new window

Revocation of consent for release of protected health information – Spanish , PDF opens new window


Multi-language translator service

Multi-language interpreter services contact information


State-specific documents and resources

View state-specific documents and resources related to Humana’s offerings in your state.

Texas – Humana ChoiceCare® PPO Member Handbook , opens new window

Texas – Humana Preferred® PPO Member Handbook , PDF opens new window

Texas – HMO Premier Network Handbook , PDF opens new window

Texas – Austin HMOx Network Handbook , PDF opens new window

Texas – Houston HMOx Network Handbook , PDF opens new window

Texas – San Antonio HMOx Network Handbook , PDF opens new window

Texas – Waco HMOx Network Handbook , PDF opens new window

Texas – National POS Handbook , PDF opens new window

Texas – Humana Trademark KelseyCare Network Handbook , PDF opens new window

Texas – Humana Preferred POS Network Handbook , PDF opens new window

Utah – Access to Health Care Providers in Rural Counties , PDF opens new window

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. View Treatment Cost Calculator

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.

Medical Pre-Enrollment Disclosure Forms

Dental, Vision & Life Benefits Regulatory & Technical Information – English, PDF opens new window
Dental, Vision & Life Benefits Regulatory & Technical Information – Spanish, PDF opens new window

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 Download Adobe Reader , opens new window