Healthcare plan rules explained in plain language

Out-of-Network liability and balance billing

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. Healthcare 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.

If you visit an out-of-network healthcare provider, you may be responsible for the maximum allowable fee which is the maximum amount Humana will pay this out-of-network healthcare provider for a particular service or set of services.

This varies depending on your plan, so please reference the below plan type for further explanation.

HMOx

If you have a Humana HMOx plan, and you visit an out-of-network healthcare provider 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

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 healthcare provider 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 plan's Explanation of Benefits (EOB) for details.

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

PPOx

If you have a Humana PPOx plan and you visit an out-of-network healthcare provider 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

Dental

Out-of-network services are from dentist and other dental care professionals that have not contracted with your plan. A dental care professional who is out of your plan network can set a higher cost for a service than professionals who are in your dental plan network. Depending on the dental care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover. Balance billing may be waived for emergency services received at an out-of-network facility.

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

Grace period and claims pending

Medical and 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 advanced 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 lasts 90 days. Your coverage will end on the last day of your first unpaid month. (For example, if your May premium is not paid 90 days after May 1st, we will only cover claims through the end of May.)

We will pay all appropriate claims for services rendered during the first month of the grace period for members receiving the federal healthcare advanced 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 advanced 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 lasts 31 days. Your coverage will end on the last day of the last paid month. (For example, if your May premium is not paid by 31 days after on or before May 1st, we will only cover claims 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.

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.

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

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

Claims Submission

Medical

In most cases, your healthcare provider 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 healthcare provider 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 Member document and forms page (select the “Individual and family” tab) and submit to:

Humana Claims
P.O. Box 14635
Lexington, KY 40512-4635
Customer Care: 1-800-558-2813

If you get insurance through your employer, go to Member document and forms page (select the “Through your employer” tab) and submit to:

Humana Claims
P.O. Box 14601
Lexington, KY 40512-4601
Customer Care department: 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 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.

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

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

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

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.

If you no longer have Humana benefits but overpaid on a previous bill, we will refund the premium within 14 business days if the payment was under $300. If the amount is over $300, 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.

Preauthorization + 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.

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
• Not more costly than an alternative service
• Performed in the least costly site

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.

Dental

There is no preauthorization requirement. However, in the event dental treatment is expected to be more than $300, you or your dentist may submit a proposed dental treatment plan prior to your treatment that we will use to estimate if your dental benefits will cover the treatment. This is optional and not required.

The dental pre-treatment plan may include a(n):

• List of services to be performed, including any supporting documentation
• Written description from the dentist of the treatment
• Itemized list of costs

The estimate of dental benefits is not a guarantee of what we will pay. It tells you and your dentist in advance about the benefits that may be payable for the covered expenses in the pre-treatment plan.

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 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.

*Coordination of Benefits
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 30 months after it was paid.

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

Explanations of Benefits (SmartEOB)

Medical + Dental

Your plan’s Explanation of Benefits (SmartEOB) 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.

After claims are processed, your EOBs will be provided via mail or electronically, depending on your communication preference.

Click here to see a sample SmartEOB, PDF opens new window and click here and learn how to read and understand the information in your SmartEOB, PDF opens new window.

Coordination of Benefits (COB)

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).

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/finder/pharmacy.

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 CenterWell Pharmacy™.

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

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

How to submit a paper claim for prescription medicines

To submit a paper claim, go to Humana.com/individual-and-family-support/tools/member-forms/ download the Prescription Drug Claim Form (200 Kb), PDF opens new window, and follow the instructions in the form.

Once complete, mail the completed form and Receipt(s) to:

Humana Pharmacy Solutions
P.O. Box 14140
Lexington, KY 40512‐4140

Out-of-network pharmacies

We understand that you may need to use pharmacies outside your plan’s network from time to time. Below you’ll find some situations that might require use of an out-of-network pharmacy.

Here are some examples, not all, that may cause you to go out-of-network:

• You can’t get a covered medicine in a timely manner because there are no network pharmacies providing 24-hour service within a reasonable driving distance.
• You’re trying to fill a covered medicine that isn’t stocked at an in-network retail or mail order pharmacy.
• You need a covered medicine related to emergency or urgently needed medical care.
• You must evacuate due to a state or federal emergency disaster declaration (FEMA) or other public health emergency declaration and cannot readily find an in-network pharmacy.

If you go to an out-of-network pharmacy for one of the reasons listed above or for any other reason, you’ll have to pay the full cost of the drug when you fill your medicine.

Please note: HMO plans do not have out-of-network benefits. If you are on an HMO plan, there is no coverage for out-of-network claims. Therefore, you will be responsible for 100% of the dispensing pharmacy’s charges.

In-network pharmacies

Humana's network pharmacies are required to automatically submit your claims online. You should always present your ID card at the pharmacy so the pharmacy can gather the information needed for this online submission.

If you do not present your ID card at the pharmacy, or the network pharmacy cannot submit your claim online for some other reason, you can pay for the prescription and submit it to Humana for reimbursement.

To submit a paper claim for reimbursement, see, “How to submit a paper claim” above.

Frequently Asked Questions

What if I must use an out-of-network pharmacy to fill a prescription for an urgently needed drug?

If this happens, you’ll have to pay the full cost when you fill your prescription if you use an out-of-network pharmacy. With certain exceptions, we will pay you back according to your out-of-network benefits if you submit a paper claim form.

What if I need medicine while I’m traveling away from my plan’s service area?

If you regularly take a prescription medication and you’re planning a trip, check your medicine supply before you leave. Try to take along all the medicine you’ll need for the duration of your trip. You may also check a network mail order or retail pharmacy to see if they can provide an extended supply.

We have a nationwide network of pharmacies that can fill your medicines, even when you’re outside your plan’s service area. If you travel outside your plan’s service area in the United States and need medicines, call a Customer Care specialist at the number above to find a network pharmacy where you can fill your prescription, or to discuss alternative options.

NOTE: Prescriptions filled at a pharmacy outside of the United States will only be reimbursed according to your plan’s out-of-network benefits in medical emergencies only.

Are there limitations to medicines received from a pharmacy?

Sometimes your doctor may need to submit additional documentation so we can process your reimbursement payment request. This can happen if you get:

• A drug that isn’t on our drug list
• A drug that’s subject to coverage requirements or limits

NOTE: HMO plans do not have out-of-network benefits. If you are on an HMO plan, there is no coverage for out-of-network claims. Therefore, you will be responsible for 100% of the dispensing pharmacy’s charges.

How long do I have to submit my paper claim for reimbursement?

You have 15 months from the date of the prescription fill to submit the claim for reimbursement.

To submit a paper claim, see “How to submit a paper claim” above.

How do out-of-network (OON) pharmacy claims affect my cost share?

Usually, out-of-network pharmacy claims result in a greater cost to both you and to the plan. Because the out-of-network pharmacy typically charges a higher total cost for the drug than in- network pharmacies, your cost share goes up. Note that out-of-network claims typically do not apply to your maximum out-of-pocket expenses and are subject to a higher deductible.

NOTE: HMO plans do not have out-of-network benefits. If you are on an HMO plan, there is no coverage for out-of-network claims. Therefore, you will be responsible for 100% of the dispensing pharmacy’s charges.

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, PDF opens new window

Prior Authorization

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

Learn more about Prior Authorization, PDF opens new window

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, PDF opens new window

Prior Authorization / Drug Exceptions

If your prescriber 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.

• Visit https://www.humana.com/provider/pharmacy-resources/prior-authorizations for more information.

Here are contacts your healthcare provider can use:

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

Use fax or mail: Your prescribing doctor can go to https://www.humana.com/provider/pharmacy-resources/prior-authorizations-professionally-administered-drugs 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: 877-486-2621

Mailing address:
CenterWell Pharmacy
P.O. Box 745099
Cincinnati, OH 45274-5099