Member Forms & Resources

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Reimbursement Forms

Case Management Request Form
HealthAmerica and Advantra Case Management Request Form

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.


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.

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
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
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
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Access the Plan Finder to find plans available in your service area and compare benefits provided by Coventry.  The choice is yours.  When you compare costs, we think you’ll see the value that our plans offer.

Do you have Medicare and Medicaid? You may be eligible for our Dual Eligible Special Needs Plan.

You can join Advantra Cares (HMO SNP) if you have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance), live in our service area, AND have both Medicare and Medicaid.
This plan is available to anyone who has both Medical Assistance from the State and Medicare.
We encourage you to call us before downloading and completing the enrollment form. We can help you make a choice that best meets your needs. Please call us. There will be someone available to speak with you Monday through Friday, 8 AM – 5 PM.

If you live in one of the following counties please call 1-800-470-4272: Erie, Fayette.

If you live in one of the following counties please call 1-866-218-9822: Berks, Bucks, Delaware, Lehigh, Montgomery, Northampton, Philadelphia.

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Additional Information
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Y0022_PDPCCP_2013_4006_1202b Approved
CMS Approved Date: 02/08/2013
Page Last Updated: 10/01/2015

© Copyright 2008-2015 Coventry Health Care

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.