Member Forms & Resources
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:
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
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
- 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
- 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
- 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
- PA Health Care Cost Containment Council
- Precertification Requirements
- Quality and Compliance - Provider Credentialing
- 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
- Receiving Primary Care
Network Provider Standards
- Standards Our Network Providers Must Meet
- Submitting a Claim for Covered Services
- What Utilization Management Is and How Decisions Are Made
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