ALPHA - HUMANA ESCALATIONS FORM

Humana Agent Information

Agent Full Name *

Agent Email *

Humana SAN#: *

Humana Member Verification Information

Humana Member Name *

Humana Member ID/Medicare ID *

Humana Member Postal Code

Humana Member DOB *

Humana Member Issue

Detailed Description of the Member Issue *

Desired Resolution *

Does the member need access to care? *

*Access to care would allow the member to get medications or see a doctor as if they are active while we are trying to resolve the issue. However if it is determined that the enrollment is not valid they would be responsible for the difference in costs.

Humana Escalations Document Upload

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