Documents and forms for Humana Healthy Horizons in Louisiana Members

Change of address form

If your home or mailing address changes, you have to let the Louisiana Department of Health (LDH) know. If you don’t, you may lose your coverage or miss out on key health plan information and reminders. After completing the form, you can return it by email or fax.

Louisiana Department of Health Change of Address form – English, PDF

Louisiana Department of Health Change of Address form – Spanish, PDF

Or, to update your information through us, call us at 1-800-448-3810 (TTY: 711), Monday – Friday, from 7 a.m. – 7 p.m.

Welcome Kit/Quick Start Guide

All new members get a Welcome Kit/Quick Start Guide in the mail. You also can view it below. Your Welcome Kit/Quick Start Guide includes the information you need at the start of your enrollment in Humana Healthy Horizons^® in Louisiana

Welcome Kit/Quick Start Guide – English, PDF

Welcome Kit/Quick Start Guide – Spanish, PDF

Adobe Reader is needed to view PDFs. If you do not have Adobe Reader, download it today.

Health Needs Assessment (HNA)

The HNA is a set of health questions for you to answer. Your answers will help us make sure you get the care you need. Your Welcome Kit/Quick Start Guide includes an HNA and a postage-paid envelope in which to return it.

Health Needs Assessment – English, PDF

Health Needs Assessment – Spanish, PDF

Earn $30 in rewards through Go365 for Humana Healthy Horizons^® if you complete your HNA during the first 90 days of enrollment in Humana Healthy Horizons^® in Louisiana

Learn more about Go365 for Humana Healthy Horizons

Behavioral health documents and forms

These documents apply to all parishes where Humana Healthy Horizons coverage is available.

Behavioral Health Concurrent Review for Inpatient and Partial Hospitalization Program 

Behavioral Health Initial Review for Inpatient and Partial Hospitalization Program 

Behavioral Health Individual Placement and Support Request Form 

Behavioral Health Community Based Outpatient Services Request Form 

Behavioral Health Neuropsychological Testing Request Form 

Behavioral Health Personal Care Services Request Form 

Behavioral Health Peer Support Request Form 

Behavioral Health Rehabilitation Request Form 

Behavioral Health Crisis Services Treatment Request Form 

Behavioral Health Applied Behavioral Health Authorization 

Behavioral Health Psychiatric Residential Treatment Facility (PRTF) Prescreening Request Form

Behavioral Health Psychological Testing Authorization Form 

Physical health documents and forms

These documents apply to all parishes where Humana Healthy Horizons coverage is available.

Physical Health Authorization Request Form 

Physical Health Outpatient Therapy Authorization Request Form 

Request for Medicaid EPSDT – Personal Care Services 

Request for Prior Authorization – EPSDT Personal Care Services 

EPSDT Personal Care Services – Social Assessment Form 

EPSDT Personal Care Services – Daily Schedule

EPSDT Personal Care Services – Plan of Care

Member Handbook

Refer to your Member Handbook for information your plan, benefits, and covered services

Member Handbook – English

Member Handbook – Spanish

Provider directories

To find information about in-network doctors, specialists, and healthcare facilities near you:

• Refer to the provider directory in the region where you live, or
• Use our Find a Doctor service

Region 1 - Metropolitan: Jefferson, Orleans, Plaquemines, and St. Bernard parishes

• Provider Directory – English and Spanish (Part 1 of 2)
• Provider Directory – English and Spanish (Part 2 of 2)

Region 2 – Capital Area: Ascension, East Baton Rouge, East Feliciana, Iberville, Pointe Coupee, West Baton Rouge, and West Feliciana parishes

• Provider Directory – English and Spanish (Part 1 of 2)
  
• Provider Directory – English and Spanish (Part 2 of 2)

Region 3 – South Central: Assumption, Lafourche, St. Charles, St. John the Baptist, St. James, St. Mary, and Terrebonne parishes

• Provider Directory – English and Spanish

Region 4 – Acadiana Area: Acadia, Evangeline, Iberia, Lafayette, St. Landry, St. Martin, and Vermillion parishes

• Provider Directory – English and Spanish

Region 5 – Imperial Calcasieu: Allen, Beauregard, Calcasieu, Cameron, and Jefferson Davis parishes

• Provider Directory – English and Spanish

Region 6 – Central: Avoyelles, Catahoula, Concordia, Grant, LaSalle, Rapides, Vernon, and Winn parishes

• Provider Directory – English and Spanish

Region 7 – Northwest: Bienville, Bossier, Caddo, Claiborne, Desoto, Natchitoches, Red River, Sabine, and Webster parishes

• Provider Directory – English and Spanish

Region 8 – Northeast Delta: Caldwell, East Carroll, Franklin, Jackson, Lincoln, Madison, Morehouse, Ouachita, Richland, Tensas, Union, and West Carroll parishes

• Provider Directory – English and Spanish

Region 9 – Florida Parishes: Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington parishes

• Provider Directory – English and Spanish

Primary care provider change request form

To change your primary care provider (PCP), use our online PCP change request service in your MyHumana account (desktop version only) or complete and submit the PCP Change Request Form.

PCP Change Request Form

Advance directive/Living will

An advance directive, also known as a "living will," is a written legal document that instructs healthcare providers who should make medical decisions on your behalf if you cannot do so. We include below more information about advance directives/living wills:

End of Life Registry Programs through the Louisiana Secretary of State’s office

Advance Directive for Mental Health Treatment

Advance Directives

Preferred Drug List (PDL)

The Louisiana Department of Health (LDH) PDL:

The LDH Single PDL is a list of medicine Louisiana Medicaid recipients can use if prescribed. A Pharmacy and Therapeutics (P&T) Committee recommends medicine to include on or remove from the PDL. Medicine on the PDL is identified as preferred or nonpreferred and includes information about prior authorization requirements.

Review the current LDH Single PDL

Please note: The LDH Single PDL is not all-inclusive. Many medications listed on the single PDL are covered.

Over-the-counter (OTC) catalog and order form

Humana Healthy Horizons in Louisiana members:

• Have a $75/month allowance to spend on OTC health and wellness items through the mail
• Can use Humana’s mail-order pharmacy, CenterWell Pharmacy™, which will send medicine to your home

To get started:

• Look up available OTC items in the Humana Health and Wellness Catalog and Order Form

Humana Health and Wellness Catalog and Order Form – English

Humana Health and Wellness Catalog and Order Form – Spanish

• Write down your order on the Order Form
• Submit your order:
  • By mail:
    CenterWell Pharmacy P.O. Box 1197 Cincinnati, OH 45201-1197
  • By phone:
    Call CenterWell Pharmacy at 1-855-211-8370 (TTY: 711). Customer Care Representatives are available Monday – Friday, 8 a.m. – 11 p.m. and Saturday, 8 a.m. – 6:30 p.m., Central time.
  • By fax: 1-800-379-7617

Call the number on the back of your ID card if you have questions about your benefit.

Health benefits claim form

To request reimbursement of out-of-pocket expenses tied to a Humana Healthy Horizons in Louisiana covered benefit, please complete and return a Health Benefits Claim Form.

Health Benefits Claim Form

Expanded Benefits Reimbursement Form

We hope you don’t have to pay out of pocket for the benefits you get as a Humana Healthy Horizons in Louisiana member. If you do, let us know by filling out a reimbursement claim form, and you may get a refund.

Fill out the form below to send a reimbursement claim.

Expanded Benefits Reimbursement Form – English

Expanded Benefits Reimbursement Form – Spanish

Grievances and appeals forms

We want you to be happy with the care you get. We hope you get the best care possible.

If you are not happy with any part of your healthcare plan, Member Services, your doctor, or a facility, you can send in a grievance.

You also can appeal a claim or a denied service using the grievances and appeals forms.

To have someone send an appeal or grievance for a covered member, we must have a completed Appointment of Representative Form on file.

Learn more about grievances and appeals, and access our form for submitting a grievance or appeal online

Legal and privacy notices

The legal and privacy notices below provide information about:

• How Humana uses, and when we might share, your personal information
• Your privacy rights

Individual privacy rights – English

Individual privacy rights – Spanish

Rights and responsibilities – English

Rights and responsibilities – Spanish

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Notice – English

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Notice – Spanish

HIPAA Privacy Complaint Form

To give us permission to share your medical information with someone, you must complete and send back to us a Consent for Release of Medical Information and a Consent for Release of Protected Health Information

Consent for Release of Medical Information – English

Consent for Release of Medical Information – Spanish

Consent for Release of Protected Health Information – English

Consent for Release of Protected Health Information – Spanish

Notice of Non-Discrimination 

Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate or exclude people because of their race, color, religion, gender, gender identity, sex, sexual orientation, age, disability, national origin, military status, veteran status, genetic information, ancestry, ethnicity, marital status, language, health status, or need for health services.

Non-Discrimination Notice – English

Non-Discrimination Notice– Spanish

Notice of Availability of Language Assistance Services and Auxiliary Aids and Services

Humana Inc. and its subsidiaries comply with Section 1557 by providing free auxiliary aids and services to people with disabilities when auxiliary aids and services are necessary to ensure an equal opportunity to participate.

Auxiliary Aids and Services Notice – English

Auxiliary Aids and Services Notice– Spanish

Detecting, preventing, and reporting healthcare fraud

As part of our efforts to improve the healthcare system, we are committed to:

• Detecting, correcting, and preventing healthcare fraud
• Educating our members about how to detect and/or prevent fraud

Learn more about detecting, preventing, and reporting healthcare fraud and how you can help

Performance measurement

Refer to the below information to see:

How we’re measured as a health plan and

How we’re doing

Guide to Healthcare Effectiveness Data and Information Set (HEDIS^®) measurements

State of Health Care Quality Report (NCQA)