How to complete a Paper Application 2014

How to complete
a Paper Application
Objective and Scope
Objective of the project
 To provide the necessary steps to accurately complete a paper application.
To highlight the changes to the AEF (Abbreviated Enrollment Form) and the OSB (Optional Supplemental Benefit)
 Individual Medicare paper applications
Electronic enrollment channels
Special Needs Plans (SNP) forms
Please print clearly and press hard.
Use blue or black ink only.
Completely fill the ovals.
Print clear numbers and capital block letters in the boxes.
Print only one letter or number in each box.
If you make a mistake, fix it by crossing out the box with an X. Put in the correct letter or number above or below the box as
When filling out dates, be sure dates appear in the MMDDYYYY format. Don’t use dashes or spaces.
SAMPLE CHECK (If you are choosing the auto bank withdrawal.
Important things to know:
Something as simple as failing to properly mark the application
can cause the application to pend and delay the start of coverage
Humana Medicare Enrollment Form: Medicare
Medicare Information: Take this directly from your Medicare Card
Print your last name
Your first name
Medicare ID number
Hospital Part A and Part B
effective dates
MMDDYYYY (07062012)
Humana Medicare Enrollment Form: Plan
In this section completely fill in the circle
Are you currently on Medicaid?
• If so, Please fill out the Medicaid number
section on the right.
Name of plan you are enrolling in:
• Fill in the circle for Plan.
Group ID and Benefit number
• Your agent will provide this number to you
Plan option number :
• The agent will review this number. Note: The
plan number will have only 3 digits after the
The Agent SAN number is required at the top.
• This will be provided to you but your agent
Humana Medicare Enrollment Form: OSB
Optional Supplemental Benefits
To add any of the optional supplemental benefits
fill in the circle next to the ones you want to enroll
Note: These are added benefits with an additional cost
Humana Medicare Enrollment Form: ESRD
ESRD Question – Please select accordingly
Residential address – This must be a physical address – do not list a PO Box in this field. The county must also be listed
Telephone number – This should be a number that Humana can use to contact you.
Date of birth - This will be 2 digit month, 2 digit day and 4 digit year.
Sex – Fill in the circle that matches your gender
Mailing address – only complete this section if your mailing address is different then your residential address. A PO Box can be used for
the mailing address.
Humana Medicare Enrollment Form: Contact Info
Every page of the application will require your Medicare ID number
• Other contact information (optional) – enter the number that the Humana agent can best contact you and select what time of day.
• Email address – this is optional
The email address will allow Humana to send you non-enrollment plan materials
via e-mail. Ex: New Member Orientation invitation.
• Primary Care Physician (PCP) – this is only needed if enrolling in an HMO or Prime Choice PPO
• Requested (but optional) for PFFS and some PPO.
The agent can look up the PCP number in the provider directory.
Humana Medicare Enrollment Form: Other Health Coverage
Answer Yes or No to every question
If the answer is Yes to any question
additional information will be needed.
Question 1–3: Other medical health coverage once enrolled.
"This is referring to you having other coverage, whether under your spouse's policy or some other coverage.“ If you are covered under your
spouse’s policy, that information is needed.
Humana Medicare Enrollment Form: Nursing Home
Remember every page of the application will require your Medicare ID number
Question 4: Resident in a nursing home. If the answer is Yes, please provide the facility information.
Humana Medicare Enrollment Form: Payment
Select how you would like to pay for the plan
Social Security deduction – only requires marking the circle. This is the preferred method of payment.
Coupon book – only requires marking the circle.
Electronic Fund Transfer (Bank deduction) – will require bank information in Depository section.
Auto Credit Card Charge (Credit card payment) – will require credit card information.
Humana Medicare Enrollment Form: SEP
Special Election Period Statements
Enter your Medicare
ID number at the top.
If this is not your Initial Enrollment or the Annual
Enrollment, you may be using a Special Election
If you are unsure of your election period, please
the agent.
Humana Medicare Enrollment Form:
Important Information
Enter your Medicare ID number.
Page 5 and 6 are review pages that only require
your Medicare ID number.
These pages can be left
With the member. The do not need
to be faxed with the application.
Humana Medicare Enrollment Form: Signature
Enter your Medicare ID number
Signature of applicant – this is the person being insured or the Power of Attorney for the insured. Please
sign and date.
If unable to sign your name you may just put an X
(We would prefer any other indication of signature rather than an X if possible)
If an P.O.A does sign the
application, the bottom portion
must be filled out.
Don’t forget to select the
language preference here at the
Humana Medicare Enrollment Form: Agent Use Only
Proposed effective date: only need to add the month.
Group ID and Benefit Number : These numbers are found on
the customer number grid.
Date: Date the application was signed
Scope of Appointment Type: 3 digit code that represents where
the appt. was completed.
Scope of Appointment ID Number:
Paper Application – number under the bar code
IVR – The ID number will be the confirmation number
MAPA : is the application number
Thank You for your time and attention.