Reimbursement Forms

Case Management Request Form

HealthAmerica and Advantra Case Management Request Form

Flu Vaccination (OH)

For members in Ohio seeking flu vaccination reimbursement. Contact Customer Service with specific benefit questions.

Flu Vaccination (PA)

For members in Pennsylvania seeking flu vaccination reimbursement. Contact Customer Service with specific benefit questions.

Member Medical Reimbursement Form

Return the completed form and applicable receipts to the address for your health plan listed in the attached document.

Part D Vaccine & Administration (Injection) Claim Form

This claim form is for reimbursement of covered Part D vaccines and their administration (injection). Please consult your Evidence of Coverage for specific coverage information.

Prescription Drug Claim Form

Request reimbursement for prescription drugs by completing this form.

Additional Member Information

Appointment of Representative Form

You can name a relative, friend, advocate, doctor, or someone else to be your appointed authorized representative. This will give that person the right and ability to act for you. Some other persons may already be authorized under state law to act for you. If you want someone to act for you, then you and the person you want to act for you must sign and date a statement that gives this person legal permission to act as your authorized representative. A form that you can use can be found here.

This statement or form must be sent to Advantra at:

HealthAmerica
PO Box 7770
London, KY 40742-7770

You can call us at 1-800-290-0190 or TTY/TDD 711 Telecommunications Relay Service for the hearing impaired, 8:00 a.m. - 8:00 p.m., local time, seven days a week.

Electronic Funds Transfer (EFT) Form

Use this authorization agreement form for ACH debit to allow your plan to withdraw your monthly plan premium payment from your checking or savings account on the 10th of each month.

Help with Diabetes

• Product support and tips from LifeScan.
• Recipes, meal planning, and fitness tips.
• Reminders for testing and supplies.

Advance Directives (PA)

Advance Directives ("Living Wills") for Health Care in Pennsylvania

Advance Directives (OH)

Advance Directives ("Living Wills") for Health Care in Ohio

NCQA Recognition Directory

The Diabetes Physician Recognition Program (DPRP) recognizes physicians for demonstrated high quality care patients with diabetes.  Note: not all DPRP physicians participate in the HealthAmerica and HealthAssurance network.

Medical Technology Evaluation

How We Evaluate New Medical Technology

Complaints/Appeals

Filing a Complaint or Appeal

Provider Search (OH)

Finding a Network Health Care Professional and Information about Them - Ohio

Provider Search (PA)

Finding a Network Health Care Professional and Information about Them - Pennsylvania

Chronic Disease Management

Information about Our Chronic Disease Management Programs

Leapfrog Survey

To promote safe practices, HealthAmerica encourages our network hospitals to respond to the national Leapfrog hospital safety survey. The Leapfrog Group works with medical experts nationwide to identify problems and propose solutions to improve hospital safety.

Member Rights & Responsibilities

Member Rights and Responsibilities

Privacy Practices

Notice of Privacy Practices (English)

Privacy Practices (Spanish)

Notice of Privacy Practices (Spanish)

Emergency and Out of Area Care

Obtaining Care When Outside the Service Area

PHC4

PA Health Care Cost Containment Council

Precert Requirements

Precertification Requirements

Provider Credentialing

Quality and Compliance - Provider Credentialing

Quality Improvement

Quality and Compliance - What Our Quality Improvement Program Does for You

Quality Improvement Newsletter

Quality and Compliance - Quality Improvement Newsletter

Health Care Law & Legislation

Quality and Compliance - Health Care Law and Legislation

Primary Care

Receiving Primary Care

Network Provider Standards

Standards Our Network Providers Must Meet

Submitting Claims

Submitting a Claim for Covered Services

Utilization Management

What Utilization Management Is and How Decisions Are Made