Member Forms & Resources

Member Forms &  Resources Section Banner Image

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:

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
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
Additional Information

New 2014 QIO Contact Information

Not yet a Member?

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.

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 800-470-4272: Allegheny, Armstrong, Beaver, Bedford, Butler, Clearfield, Crawford, Erie, Fayette, Greene, Lawrence, Mercer, Somerset, Washington, or Westmoreland.

If you live in one of the following counties please call 866-218-9822: Adams, Berks, Bucks, Carbon, Centre, Chester, Clinton, Columbia, Cumberland, Dauphin, Delaware, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montgomery, Montour, Northampton, Northumberland, Perry, Philadelphia, Schuylkill, Snyder, Sullivan, Union, Wyoming, or York.

find a plan

Coventry Health Care offers products across the county. Compare and find the best plan for you.

Find 2015 Plans >>

My Online Services

Access your health care information & manage your personal health with our wellness tools.

Login or Register Now >>

Additional Information
Get Adobe Reader

Page Last Updated: 12/17/2014
CMS Approved Date: Approved 02/08/2013
CMS Document ID: Y0022_PDPCCP_2013_4006_1202b

© Copyright 2008-2015 Coventry Health Care

Coventry Health Care is a Coordinated Care plan with a Medicare contract. First Health Part D is a Medicare-approved Part D sponsor. Enrollment in our plans depends on contract renewal.