Documents and Forms

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 Health Benefits Claim Form to:

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.

International Health Benefits Claim Form – English

International Health Benefits Claim Form – Spanish

Medicare Advantage and Prescription Drug Plan

Disenrollment Instructions and Form

Form to Request to End Plan (Disenroll) and Special Election Questionnaire – English

Form to Request to End Plan (Disenroll) and Special Election Questionnaire – Spanish

Prescription Drug Claim Form

Return completed forms by mail, fax or the PromptPA portal

Medicare Prescription Drug Claim Form for Member Reimbursement – English

Medicare Prescription Drug Claim Form for Member Reimbursement – Spanish

Commercial Prescription Drug Claim Form – English

Commercial Prescription Drug Claim Form – Spanish

Declaration of Prior Prescription Drug Coverage Form

Declaration of Prior Prescription Drug Coverage – English

Declaration of Prior Prescription Drug Coverage – Spanish

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

Downloadable request forms for Part D prior authorization

Request for Medicare Prescription Drug Coverage Determination Form – English

Request for Medicare Prescription Drug Coverage Determination Form – Spanish

Learn more about the Part D drug prior authorization process

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

Appeal, Complaint or Grievance Form – Spanish

Appeal, Complaint or Grievance Form – Chinese

Learn more about the Medicare drug (Part D) Coverage Redetermination Process

Learn more about the Medicare Advantage (Part C) Coverage Reconsideration Process

Grievances and Appeals/Inquiry Directory

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

Appointment of Representative form for appeals and grievances

If you’re 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’re authorized to work with Humana on his or her behalf.

Appointment of Representative Form – English

Appointment of Representative Form – Spanish

You also can get the AOR form on the Centers for Medicare & Medicaid Services website

Power of Attorney (POA)

You have 2 ways to submit a Power of Attorney form to Humana:

1.) Submit a Power of Attorney form online.

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 Injury Report and File Status Request 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.

CenterWell Pharmacy™ mail delivery forms

CenterWell Pharmacy Registration and Order Form – English
CenterWell Pharmacy Registration and Order Form – Spanish
Physician Fax Form – English
Physician Fax Form – Spanish

Member blocking request

Disable access to your secure member website for yourself or a family member.

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 dental benefits claim form or 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.

Humana Vision and Humana Vision PLUS claim form

For members seeking a reimbursement after visiting an out-of-network provider.

Out-of-network vision services claim form

Spanish out-of-network vision services claim form

Group Pre-enrollment Disclosure Guides

Dental and Vision Regulatory Pre-enrollment Disclosure Guide

Michelle’s Law

Process for continued coverage for full-time students on a medical leave of absence. 

Michelle’s Law – H.R. 2851

Appointment of Representative form for appeals and grievances

If you’re filing an appeal or grievance on behalf of a Humana plan member, you need an Appointment of Representative (AOR) form or other appropriate legal documentation on file with Humana so that you’re authorized to work with Humana on his or her behalf. 

Appointment of Representative Form – English

Group life claim forms 

Accelerated benefits claim form

Group life claim form – English

Group life claim form – Spanish

Dismemberment benefits claim form

Waiver of premium initial claim form

Waiver of premium continuation claim form

HumanaLife Beneficiary Designation

Life authorization form

Group disability income claim forms

Application for short term disability income benefits

Application for short term disability income benefits – Spanish

Application for long term disability income benefits

Application for long term disability income benefits – Spanish

Humana Short-Term Income Protection – Claim Form

Continuing Short Term Disability Claim Form

Group disability income state notices

Group Long Term Disability State Notices

Group Short Term Disability State Notices

Group Pre-enrollment Disclosure Guides

Disability Income Regulatory Pre-enrollment Disclosure Guide

Life Regulatory Pre-enrollment Disclosure Guide

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

Medical Forms

New York Medicare Supplement Narrative Summaries

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: 

Arizona Medical Appeals Packet – English version

Arizona Medical Appeals Packet – Spanish version

Arizona Dental and Vision Appeals Packet – English version

Arizona Dental and Vision Appeals Packet – Spanish version

You can file an appeal through the Exceptions and appeals – Insurance through an employer page. Select the appeal you’d like to make and follow the instructions on that page.

Group Dental handbooks

Texas - DHMO Handbook HD 405

Texas - DHMO Handbook HD 410

Texas - DHMO Handbook HD 415

Texas - DHMO Handbook HS 405

Texas - DHMO Handbook HS 410

Texas - DHMO Handbook HS 415