ALPHA - MEMBER ESCALATIONS FORM

Agent Information

First Name *

Last Name *

Email *

NPN #: *

Carrier *

Carrier Agent #

Member Verification Information

Member Name *

Member ID/Medicare ID *

Member Postal Code

Member DOB *

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