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Humana Medicare MarketPOINT Paperless Application

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1. Verification It is Humana policy to complete a verification on all applications Verification for an OSB application is the O B option and it is automatically selected O B Rik de rh hod I a 1 ie 1 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 111 07 23 2012 New Member Orientation New member orientation will go into more detail about how to use your plan and give valuable info on different programs that we have select Yes or No If no you must use the drop down and select a reason why This will write to the Smart Pad in CDS NMO New Member Orientation Reason for not attending MMO Would vou like to attend MMO ee select Reasor Yes Ono o O E Mot Interested Mo Seminars Available for Location Selected Member has already attended Member Undecided Other Selecting Yes will not enroll the member in an orientation class Materials Used select all the materials that you used during your Appointment This information will write to the Smart Pad in CDS Materials Used MAPO Power Point Presentation MA Power Point Presentation POP Power Point Presentation Summary of Benefits Walue Added Services Benefit and Provider Leaflet Compensation sheet Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 112 07 23 2012 Member Au
2. Optional Email Address Dental Facility Number is required for DHMO plans Pd onl Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 120 07 23 2012 Free Standing Benefits FSB Dependents To add a dependent click the Demographics Dependents Payment Agent Only blue link Add Dependents Ada Dependents Dependent added in error click the red Remove link Demographics Dependents Payment Agent Only Select Type spouse or child Remove Address same as Optional Humana Medicare Re enter Humana Medicare primary insured Date of Birth Member ICHICN Mernber IDVHICN slic dia ee ee member box ae _ Last Mame First Mame Middle Initial Gender will pre fill once name is added Social Security number is not required for the spouse or child Add Dependents To add a new dependent click Add dependents again Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 121 07 23 2012 Free Standing Benefits FSB Payment Premium e There is a 1 Administrative fee e One time enrollment fee e Single payment option Demographics Dependents Payment Agent Only Premium Your Monthly Premium 25 08 Monthly prerniurn ncra ADMIMSHaINe Tee One time Enrollment Fee non refundable Total Initial Payment Single Payment Option Saves SIY Payor Same a
3. Where they heard about the plan DMS call HGC WLMT Veteran Referral Self Referral etc Location e where the application was completed e may not be where the lead was sent which would be Tier 2 e In home appt was scheduled but directed to WLMT for convenience etc Source P nal What was the source for ihis sale Tieri Select Source v Ter Salact Soue Ahal was he location for this sale oleae Location K Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 104 07 23 2012 Optional Supplemental Benefit Enrollment Form Products Discussed Please select ALL that apply This selection is used as a reminder for you It will write to the keywords section The products discussed should match your SCOPE Once you have completed all the fields click Save When saved the Application number will appear Application 6MTRL846AI13GCIiBaved Successfully Click OK Once you have saved the information Review and Sign you are ready to Review and Sign Was this Sale originated from a WalMart Store Every time you click Review and Sign you will be asked if this sale originated from WalMart If Yes enter the store ID i If No leave ID blank and click no Store ID e Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved 105 07 23 2012 Humana Internal Use only Online Service Agreement
4. 5elect Reason NMO New Member Orientation _ s JX Would you like to attend WMO Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 71 07 23 2012 Mot Interested No Seminars Available for Location Selected Member has already attended Member Undecided Other Saving the Application To ensure your application signature is Saved you must hit the Save and Close bution located at the bottom of the application If you click the X in the upper corner the signature will not save Click on the Save and Close button to save the application Save and Close S Error Errors have been found Please correct before signing lf you make a mistake or forget something on the review and sign Check the following Signature information 1 Witness Last Name Required page you will see the error box 2 Witness First Name Required showing what corrections need 3 Witness Relation Required to be made Check the following Verifier Information 1 Provide Verification information or Reason for not verifying Application Updated A message box will indicate the Application 6MTRL85JDH42KRG Successfully Saved application has been saved Your application is now completed Once you click OK you will return to the MAPA Workbench Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Inter
5. Client Signature Captured VWitness Translator Last Mame Ss Falation E Note If the digital signature pad fails to capture the signature complete a paper application and contact CSS for a replacement Signature pad Put the signature tablet in a position where the client can comfortably sign on the tablet screen The tablet screen will light up and your client can sign on the tablet using the attached stylus Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 68 07 23 2012 Capturing Signatures Client As your client signs on the dotted line his her signature will appear in the Signature window on the laptop screen lf the client does not like the appearance of their signature they can try again after the signature on the tablet screen is cleared The signature can be cleared in one of two ways SEI Ee The client can tap on CLEAR on the tablet or e The agent can click on the Clear Client Signature button on the laptop When the client is satisfied with their signature the signature can be captured in one of two ways Capture Signature The agent can click on the Capture Client Signature button on the laptop screen The client can tap on OK on the tablet or Signature signature of applicant or authorized legal representative incluaing valid Power of Attorney Legal Guardian ete Once the signature Is captured a Client Client Sig
6. REAL For Me Medicare Supplement Single Husband and Wife Client Information Enrollment in a Medicare Advantage Plan is required for Enrollment in a Humana Optional Supplemental Benefit Zip Code County Current Humana Medicare Advantage Plan 40239 BULLITT KY v HumanaChoicePPO R5826 008 v My Current monthly premium is if applicable po Humana Medicare Advantage Effective Date Optional Supplemental Proposed Effective Date Effective date is 10012010 fowo calculated based on 30 days from current plan This must be the same election period used on the original application Name of Optional Supplemental Benefit you are enrolling in If youre currently enrolled in an OSB you must select it on this form to continue receiving this benefit Select OSB offerings may not be available in all areas OSB Riders Riders OOM YOPRTION VISION Name of Plan you are Enrolling in fumaneOhoicePFO Resa Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 100 07 23 2012 Optional Supplemental Benefit Enrollment Form Never use a PO Box in the address The address must be a street address Address Last Narne First Marne l Residential Address 1 Address A Ant ale ty ip Code County iOS mume Phone 502 655 8806 Member ID Number As listed on your Humana Identification card po Medicare Claim Number po This num
7. Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 1 10 01 2012 Table of contents Section Page Introduction 3 How to log in 4 MAPA Workbench 5 Synchronizing 10 Downloading 12 Creating an Application 20 Scope of Appointment 22 Individual Application 31 Medicare Supplement Application 55 Group Application 75 Abbreviated Enrollment Form 90 Optional Supplemental benefits 99 Member Authorization Form 112 Free Standing Benefits 118 Uploading 130 Application Status 139 Cloning an Application 142 Copy an Application 143 Deleting an Application 144 Canceling and Application 145 Member Receipt 146 Troubleshooting Restore 148 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 2 10 01 2012 Introduction to MAPA This module will introduce you to the Medicare Advantage Paperless Application MAPA It will be your guide for downloading information completing applications and uploading information to the server MAPA is installed on your laptop It can be used throughout the day as you work with your customers without being connected to the internet The only times when you will need an internet connection are e At the beginning of your day when you download the updated plan data current day appointments contacts and contact sets from the server to the laptop
8. Contact Search Appt Time Last Name FirstName Address City State Lip Phone May 102010 2 00PM HILL ABBI Palmetto FL 34221 941 723 9432 May 10 2010 9 00AM MONSTER HENRY 607 E3RD STAPT PELLA lA 50219 641 628 3631 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 119 07 23 2012 Free Standing Benefits FSB Demographics Demographics Client Information Social security is required Zip Code County Date of Birth Social Security Number 40299 BULITKY o o Ky 06454919 519 Available Flans The member must agree to these terms 8P Denta ssl I fome _ By enrolling in this plan you are agreeing to a one year minimum contract with HumanaOne You will not be allowed to cancel this plan until one year from your selected effective date Address a PO Last Name First Name Middle Initial Box can be used MONSTER HENRY E r Address 1 Permanent Address 2 Ant City state County There are phone pum number fields one is Daytime Phone Optional Home Phone Required Bente optional the other required a Enem Male Female Language Preferences Other Language w BE Optional Humana Medicare Mernber IDHIEN Re enter Humana Medicare Werber IDVHICN Dental Facility Number C By providing this address you are giving Humana permission to send non enrollment materials via email
9. You must read the agreement to the member and have them Place a ggn the box then click Next Ee Agreement a Online Service Agreement Agreement with Humana This agreement is between you and Humana Inc on behalf of its affiliates Consent to Electronic Transactions I the User and Humana acknowledge and agree to the following provisions 1 To conduct this enrollment and any changes made to this enrollment information through the use of an electronic transaction which will be verified by the use of an electronic signature 2 This consent to conduct an electronic transaction only applies to enrollment services 3 That may request that this Agreement be terminated If terminated paper access to enrollment services and forms will be distributed at no cost to me if an address phone number and a contact name are provided ta a Humana representative 4 That may request a paper copy of this recorded transaction For More Information Humana 500 VV Main Street Louisville RY 40202 By checking this box you acknowledge you have read and understand the above information Ask the member if they Agree or Disagree to the service agreement Click the appropriate box Note if the member disagrees you will need to start over with a paper application Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 106 07 23 2012 Optional Supplementary Benefit Summary Rev
10. Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 138 07 23 2012 Clone an Application sometimes you will be working with a client and need to complete another application for a related family member To keep from having to start with a blank application you can create a Clone a copy of the client s application that is stored on your laptop make the necessary changes for the client s relative and save the new member s application You create a clone of an application by clicking the application record this will highlight the record and make the Clone Application button accessible and then clicking on the Clone Application button Application Search Search By AI Complete Incomplete Clone App E Load App Cancel App Last Name First Name Address City State w Pine Status Tree Crab 9898 Willow Tree Louisville KY 0299 Incomplete K 40220 Incomplete 1212 RiverRd Louisville Ko aw P2922222 Powder 1212 Cotton lane louisville Y 40299 222 222 2222 Incomplete Diamond 1515 Willy street Louisville011999 KY 40299 Complete A copy of the application will appear containing the members demographic information just as it was stored in the original You can now make any necessary additions changes to the application and process it in the Same way as you did for the client Demographics Medicare Card Clinical Qualifying Plan Specific Payment Ag
11. Suite 720 Las Vegas NV 7674 2025 W Henderson Columbus OH 17693 1915 SNOW ROAD FARMA OH 17694 4436 Western Avenue Knoxville TN 0614 T11 W Wheatland Road Duncanville TX 10625 1000 N Green Valley Parkway Suite 720 Henderson NV For Training Purposes Only Not CMS Approved 07 23 2012 STATE Medicare Supplement Application Agent Only Once the Agent only tab is completed click Save then Review and Sign Demographics Medicare Card Other Coverage Medical Questions Payment Agent Only Office Use Only Plan Representative REP Affinity Partner GR p NOE J po Date Agency Agency ID Affinity Partner Location BN aa TEE EF Agent Code MGA Code Referring Broker Name Referring Broker SAN Campaign 0305046521 All health insurance policies sold to the applicant which are still in force if none write MONE Company Type l health insurance policies sold to the applicant with in the past five years which are no longer in force if none write NONE Company Tyne ee Source Sub source House Member Type oub Type Disposition Disposition 2 Disposition 3 A Y lf there are any errors in the application you will receive the error page showing the mistakes marked in red to be fixed Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 65 07 23 2012 Medicare Supplement Application Review Review the application for accuracy If there i
12. answer to the Medicaid question Note For nursing home if yes Date refers to the date the client entered the facility Demographics Medicare Card Plan Specific Payment Agent Only Medicare Health Insurance Gomer pe S Medicare Claim Number Flease complete the information to the right exactly as it appears on your Medicare card Effective Date Please contact Humana at 1 600 633 2367 TOO _ DEX Hospital Insurance Part A 1 077 053 4406 if you need information in another format or language than what is listed O Male below Our office hours are da m to Gp m local Female Medical Insurance Part B time seven days a week lowa State UniversityOGPOP 037 104 not OE Contract Number FEF Language Preferences Are you currently enrolled in your state Medicaid program Yes O No lf Yes Medicaid Medicaid Effective Date Are you currently a resident in a nursing home or other long term care facility Yes O No If Yes complete the following Date Entered Name of Facility Address 1 Address 2 City State Zip Phone tee tt Note the language preference will write to the Smart Pad in CDS the part A and B dates Medicare effective date will write to the Benefits tab under policies Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 795 07 23 2012 Plan Specific Tab Group Application This section is reque
13. application written and signed on 7 10 2011 Upload Delay set to 7 29 2011 On 7 29 11 when an upload is completed this application will be sent Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 132 07 23 2012 Uploading To upload completed applications follow the previous process Connect to Humana and select Upload from the Agent Self Service Center page Disconnect Connect To Humana Exit MAPA Download Synchronize MAPA Home C Disable State Selection CI Disable State Selection Selected States FL GAKY Selected States K Applications must be uploaded at the end of everyday Please Wait Uploading Applications 0 out of 5 Applications Uploaded You must upload completed applications everyday Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 133 10 01 2012 Uploading An error message has been added to advise you when the lead files are running 1 2 MAPA Workbench H umana Withkasa Hebecoe Boren Fiesta iaaii a pyha ane DOART AN Agpleraen Typa Language When error received wait 30 minutes then try again Dinabie Sinis Se lates amp The Lewd Bir ia coorenily pisceming plese wall JO minutes belo uploading E ma Paaa i leach ip A i Firat am e Ban Baleli s Hisasi HA Emm 3999 MAPA ii eled ne emman U
14. do you intend to replace your current Medicare Supplement policy with this policy Have you had coverage under any other health insurance within the past 63 days For example an employer union or individual plan al lf so with what company and what kind of policy bi What are your dates of coverage under this policy If you are still covered under this policy leave END blank START END Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 56 07 23 2012 Medicare Supplement application Questioner completed Click Calculate This system will let you know if the member is eligible or not Alzheimer s Disease senile dementia organic brain Yes No Alzheimer s Disease senile dementia organic brain Yes No disorders senility disorder schizophrenia other disorders senility disorder schizophrenia other major depressive disorders mental or nervous major depressive disorders mental or nervous disorders cirrhosis alcoholism or drug abuse disorders cirrhosis alcoholism or drug abuse Acquired AIDS Rel shika Sorry You are not Eligible Rheumat bone dise OK Organ transplantation OYes No Organ transplantation fes No Not Eligible click OK and start over Eligible to enroll the system will give you the plan cost Cost to much go back to the top and select a new plan calculate again Once plan selected click
15. 2012 Scope of Appointment Form Summary Once you click Review and Sign go over the completed SOA to make sure all the Information is listed correctly A Scope of Appointment Form Summary Client Information Zip Code County JEFFERSON KY Zip and county listed correctly O Stand alone Medicare Prescription Drug Plans Part D Correct plan selected for the presentation Medicare Prescription Drug Plan PDP A stand alone drug plan that adds prescription drug coverage to the Original Medicare Plan some Medicare Cost Plans some Medicare Private Fee for Service Plans and Medicare Medical Savings Account Plans M Medicare Advantage Part C Medicare Advantage Precription Drug Plans and other Medicare Plans Medicare Health Maintenance Organization HMO A Medicare Advantage Plan that must cover all Part A and Part B health care In most HMOs you can only go to doctors specialists or hospitals in the plan s network except in an emergency Last Name First Name Ml Frey a Address 1 Address 2 APT 1515 Smelly Street DEET Member information correct City State Zip County Phone 40299 JEFFERSON KY 026 666 5666 ARR RAL Initial Method of Contact Unexpected additional attendee Medicare Claim Number Re Enter Medicare Number 123456789a 123456789a Office Use Only Plan Representative Agent Representative Phone 407608 BOJSA Aer Source Sub Source House Member Type Sub Type Appointment Date Time of Appoin
16. Applications submitted through MAPA will display the following day Paper applications submitted to ACS will display once the To Date application data has been successfully transmitted to Humana From Date 9 4 007 QB g To Date 9 15 2007 amp Select the Plan Type And Report Type you want to search on Report individual E A ie Plan Type PDP Select All Click SUBMIT Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 136 10 01 2012 MAPA reporting now offers verification reports Printer Friendly Version Export Previous The data contained in this report is for administrative use only and may not be used for marketing purposes of any kind or to solicit disenrolled members Failure to comply is a Violation of federal privacy laws and will result in legal action and disciplinary action up to and including termination 08 01 2009 09 06 2009 Verification System Digital GOOKRI4MIFTSC09 Smith Meaghan A HumanaChoice PPO H1806 001 08 31 2009 T Digital BOOKRISDLAS901 Matin Betty ee a ONOSPO09 3454235334 Adrey Bella Digital BOOKRISELSSNS1 Brown ov hi HumanaChoiceF FO R5826 06 OOM 200 Seminar Enrollment MAPA reporting now ties OSB s and SOA s to applications AE Pend Code Legend Printer Friendly Version Export Previous Dh The data contained in this report is for administrative use only and may not be used for marketing purposes of any kind or to
17. Enroll Do you now have or within the last two years have you had or been advised by a physician that you need treatment or surgery for Heart Coronary or Carotid Artery Disease not including high blood pressure Peripheral Vascular Disease C Yes No Congestive Heart Failure or any other type of Heart Failure Enlarged Heart Stroke Transient Ischemic Attacks TIA or Heart Rhythm Disorders Emphysema Chronic Obstructive Pulmonary Disease COPD or other Chronic Pulmonary disorders Have you used supplementary oxygen in the last year Parkinson s Disease Multiple or Lateral Sclerosis Huntington s Disease Muscular Dystrophy Lupus Hepatitis or Lou Gehrig Disease Alzheimer s Disease senile dementia organic brain disorders senility disorder schizophrenia other major depressive disorders mental or nervous disorders cirrhosis alcoholism or drug abuse Acquired Immune Deficiency Syndrome AIDS or AIDS Related Complex ARC or tested positive for exposure to the Human Immunodeficiency Virus HIV infection Kidney disease requiring dialysis or diabetes requiring more than 50 units of insulin daily Internal cancer leukemia or melanoma Amputation caused by disease or trauma or neuralgic or poor circulation that has caused an ulcer on the skin Do you have any paralytic conditions Rheumatoid arthritis Paget s Disease degenerative bone disease crippling arthritis vertebral or hip fractures dislocations spinal cord diso
18. Group Individual Application Type 2 OSB O Member Authorization O SOA O FSB REAL For Me O Medicare Supplement Single Husband and Wife Types of Applications AEF Abbreviated Enrollment Form use this application only when your member is making a plan to plan change the contract numbers will be the same OSB Optional Supplemental Benefits use this application when you are enrolling a member in an OSB after you have uploaded the original application and before the 30 day window SOA Scope of Appointment use application when you have an extra person at your appointment your member wants a different presentation or you are creating a future appt FSB Free Standing Benefits use this application to enroll someone in the dental or vision plan that is not tied to the Medicare plans Individual use this application for your basic MA enrollments Group use this application only for members that are associated with the groups you are eligible to write Medicare Supplement use this app for all med supp products not all states are allowed to submit electronically at this time Member Authorization this form is used to give Humana the permission to contact a Medicare member about other products Real for Me This application is used to request Real powered by Humana news and updates also to request a free copy of Retirement for Dummies and Well Being for Dummies Confidential and Proprie
19. Id and password Delegated agents Agent portal User Id and password Synchronizing Data Please Wait Downloading MedSupp Rate 33 Completed MAPA upgrade ls avallable Do you want to upqrade esa syncOnce will allow deferment of the download 3 times During the 4 synchronization the system will automatically Install the new version Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 12 10 01 2012 Download To activate Download you need to first Connect to Humana Downloading will insure that all the plan data listed is correct You must download everyday Click on Connect to Humana Humana Login Meca agents Agent portal User ID Please enter your Secured Logons User ID and Password E and password Login Delegated agents Agent portal User ID and User Name rbb1373 password Password QaRa Once you enter your User ID and password and connect to Humana the download option will activate Downloading Please Wait Downloading MedSupp Rate 33 Completed Downloading SubSource Codes 20 Completed Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 13 10 01 2012 Creating an Application Application Type Language To create an application L eEnglish Spanish Plan Type Select Language Li Humana O CarePlus Plan Type i AEF O
20. Male oes below Our office hours are Ga m to Sp m local Pamah Medical Insurance Patt B time seven days a week 01401 1598 HumanaChoicePPO R5626 008 Contract Mumber PEP Language Preferences I em Are you currently enrolled in your state Medicaid program Yes No If Yes Medicaid Eo Medicaid Effective Date Are you currently a resident in a nursing home or other long term care facility Yes Mo lf Yes complete the following Date Entered Name of Facility SSS Address 1 Address 2 City State Zip Phone 334 AAH HHE L aia PLEASE READ THIS IMPORTANT INFORMATION on health care benefits If you have health coverage from an employer or union joining i i o you If you have questions visit their website or contact their office listed in their communications If there is no information on whom to contact your benefits administrator or the office that answers questions about your coverage can help By competing this enrollment form agree to the following EERO OMe cNEMseriemesa Medicare Advantage plan and has a contract with the Federal government will need to keep my Parts A and B can only be in one Medicare Advantage plan at a time and understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan It is my responsibility to inform Humana of any a Release of Information By joining this Medicare health plan acknowledge
21. OTHER option for why an SOA was not completed prior to the appointment Please use this option and enter the reason in the text field provided for why you could not execute the SOA in advance of the appointment Your signature on the review and sign page will be sufficient for meeting the initial and date requirement stated above Office Use Only Plan Representative Agent Representative Phone 502 580 6579 SOUrCe Sub Source House Member Referral General Client Referral Type sub Type Appointment Date Time of Appointment C Current Date Time 09 17 2008 03 46 Check Current Date Time if you are creating an SOA at the same time you are going to present When creating a SOA for future appointment enter the date and time of the appointment If Scope is for follow up appointment MAPA will not allow user to schedule prior to 48hrs out from current date time Click Save when all the information is completed then Review and Sign Application Saved Review and Sign Application SOMTRL85G5QH33VY Successfully Saved Ne Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 19 07 23 2012 Scope of Appointment Review and Sign Errors have been found Please correct before signing Error page will appear if any required fields have been left blank click OK Following field s in Office use page has error s 1 Select Sub type The
22. Package Id E Source Sub Source House Member Type sub Type a soo 3 Good Serice M Disposition not available You must add at least 2 levels of disposition Select other and then add OSB Other Product Description dental or vision OSE dental and vision es Close Review and Sign Click save then review and sign when the application is completed Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 102 07 23 2012 Affinity Partners Affinity Partner VWWalhart Affinity Partner Locatian search StorelD WalMart Was this Sale originated from a WalMart Store Leave Store ID Blank Store ID select the correct Office Use Only select None Plan Representative Location REP Affinity Partner Boston Rebecca TC CL v Date Health Plan One Health Plan Services Referring Agent Agent Afinity TID Healthy American Hershend Farm Entertainment Humana Guidance Center Attachments OaAmoo1 OAM C AMOo06 Indiana Farm Gureau Insphere Kelse lf the affinity partner is Wal mart the store number must be listed If you don t know the Store ID e Click on the Search Store ID button e Leave ID blank and click Search e Enter State and City of the store WalMart Was this Sale originated from a WalMart Store State cy Ean If the affinity partner is a Humana Guidance Center the location must be
23. Translator First Name Relation ee eee If you are the authorized legal representative you must sign above and provide the following information Last Name First Name MI Address Address2 City State Zip fe xs Phone Relation to Applicant Cro Doo Oe Save and Close GR BN 235464 01 0 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 95 07 23 2012 Capturing Signatures Client As your client signs on the dotted line his her signature will appear in the Signature window on the laptop screen lf the client does not like the appearance of their signature they can try again after the signature on the tablet screen is cleared The signature can be cleared in one of two ways SEI Ee The client can tap on CLEAR on the tablet or e The agent can click on the Clear Client Signature button on the laptop When the client is satisfied with their signature the signature can be captured in one of two ways Capture Signature The agent can click on the Capture Client Signature button on the laptop screen The client can tap on OK on the tablet or Signature signature of applicant or authorized legal representative incluaing valid Power of Attorney Legal Guardian ete Once the signature Is captured a Client Client Sign Signature Captured message will appear TE and the client s 2 ae 101200 Signature Date
24. are Ga m to Sp m local Pamah Medical Insurance Patt B time seven days a week 01401 1598 HumanaChoicePPO R5826 008 Contract Mumber PEP Language Preferences I em Are you currently enrolled in your state Medicaid program Yes No If Yes Medicaid Eo Medicaid Effective Date Are you currently a resident in a nursing home or other long term care facility Yes Mo lf Yes complete the following Date Entered Name of Facility SSS Address 1 Address 2 City State Zip Phone 334 AAH HHE gt PLEASE READ THIS IMPORTANT INFORMATION on health care benefits If you have health coverage from an employer or union joining i i o you If you have questions visit their website or contact their office listed in their communications If there is no information on whom to contact your benefits administrator or the office that answers questions about your coverage can help By competing this enrollment form agree to the following EERO OMe cNEMseriemesa Medicare Advantage plan and has a contract with the Federal government will need to keep my Parts A and B can only be in one Medicare Advantage plan at a time and understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan It is my responsibility to inform Humana of any a Release of Information By joining this Medicare health plan acknowledge that the Medicare health plan will re
25. error messages below License information missing in Solar you will receive the message below instructing you to call Agent contracting Medicare Advantage Paperless Application We are not able to locate an active license for you at this time Please contact your MSA or email your license information to Agent Contracting at MP Captive Contractingehumama com or fax to 502 508 7633 Licensed for more than one territory but User Access is not updated j Medicare Advantage Paperless Application We currently do not have territories assiqned for KY state s Please contact CSS at 800 558 4444 ext 8919 opt 1 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 8 10 01 2012 Error messages continued There may be times when you try to connect to Humana an receive and error message What do the error messages mean lf SOLAR is down or AXTA is down Unable to Connect to Humana at this time Please try again later IF there is any timed out or SL is down SL or Login does not respond Please try again later IF the password is incorrect Incorrect Password IF there is a license issue but may be SOLAR is up and running License message you are not licensed appointed certified please contact ASU MSA etc etc Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 9 10 01 2012 Error
26. field e Using the drop down select the County this will activate the Available Plans Using the drop down in Available Plans select the plan option e if a Rider is available it will show up to select click in the box next to the one you want Demographics Medicare Card Clinical Qualifying Plan Specific Payment Agent Only Client Information Zip Code County Date Of Birth elaine loaded will be determined by the MA MAP HumanaChoicePPO H1806 001 IDF Riders Note everything on the demographic tab will write to CDS O MYOPTION ENHANCED DENTAL CMY OPTION YISION Last Name First Name Address 1 Address 2 APT City state Zip County Phone Mailing Address C Check here if the Mailing Address is the same as the Residential Address Address 1 City Email Address Optional Preferred Method of Communication Telephone Email Mail Person to notify in case of emergency nearest relative or friend Optional Last Mame First Marne Relationship To Applicant Once each section is completed you can change pages by clicking the Next button or use the tabs located at the top of the page Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 29 07 23 2012 Demographic Tab Individual Application Chronic Care Special Needs Plan Demographics Medicare Card Clinical Qualifying Pla
27. health coverage which would qualify you for guaranteed acceptance MOTE To be Yes Mo considered for guaranteed acceptance Humana must recewe your application along with a copy of the termination notice you recelved from your prior insurer within 63 days of termination of your prior coverage Ifyes you quality for the Preferred rates OTHER COVERAGE INFORMATION You do not need more than one Medicare Supplement policy If you purchase this policy you may want to evaluate your existing health coverage and decide if you need multiple coverage You may be eligible for benefits under Medicaid and may not need a Medicare Supplement policy lf after purchasing this policy you become eligible for Medicaid the benefits and premiums under your Medicare Supplement policy can be suspended if requested during your entitlement to benefits under Medicaid for 24 months You must request this suspension within 90 days of becoming eligible for Medicaid If you are no longer entitled to Medicaid your suspended Medicare Supplement policy or if that is no longer available a substantially equivalent policy will be reinstituted if requested within 90 days of losing Medicaid eligibility If you are eligible for and have enrolled in a Medicare Supplement policy by reason of disability and you later become covered by an employer or union based group health plan the benefits and premiums under your Medicare Supplement policy can be suspended if reque
28. of VWitness Translator or person assisting in con BAGI Witness Translatar Last Name eee Felation Sl Note If the digital signature pad fails to capture the signature complete a paper application and contact CSS for a replacement Signature pad Put the signature tablet in a position where the client can comfortably sign on the tablet screen The tablet screen will light up and your client can sign on the tablet using the attached stylus Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 46 07 23 2012 Capturing Signatures Client As your client signs on the dotted line his her signature will appear in the Signature window on the laptop screen lf the client does not like the appearance of their signature they can try again after the signature on the tablet screen is cleared The signature can be cleared in one of two ways SEI Ee The client can tap on CLEAR on the tablet or e The agent can click on the Clear Client Signature button on the laptop When the client is satisfied with their signature the signature can be captured in one of two ways Capture Signature The agent can click on the Capture Client Signature button on the laptop screen The client can tap on OK on the tablet or Signature signature of applicant or authorized legal representative incluaing valid Power of Attorney Legal Guardian ete Once th
29. release my information including prescription drug event data to Medicare who may release it for research and other purposes which follow all applicable Federal statutes and regulations onderst ag E a wm that Medicare beneficiaries are generally not covered under Medicare while out of the cobi EUG Humana ChoicePPO or Humana employed by or contracted with Hu ice from a sales agent broker or other individual understand that beginning with the completed enrollment form if have than using services out of network benefits even if received out of net Client Signature Captured ceiving services and may use my copy of this plan begins using services in network can cost less ary Humana provides reimbursement for all covered attest that arn not receiving any services or medical coverage pres OK understand that my signature on this application form means that have read and understand the contents of this appli what rules must follow in order to receive coverage with this Humana plan Signature Signature of applicant or authorized legal representative including valid Power of Attorney Legal Guard Client Sign Signature Date Capture Signature Witness Sign Signature Date Clear Signature Signature of VVitness Translator or person assisting in completion of form fother than plan representative VVitness Translator Last Name VVitness
30. selected States FL GA KY Click on the Connect to Humana buiton Enter your Agent Portal user ID and password 3 Humana Login Please enter your Secured Logons User ID and Password banin Meca agents will their agent Usor Name ipia Password DAAA and Password Agent Login Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 6 10 01 2012 Connect to Humana state Selection lf an agent is licensed in 6 or more states they must select the states they need during Connect To Humana downloading e Only 6 states can be downloaded at a time e To save the state selections so they do not Disable State Selection need to be selected at each down load Selected States FL GAKY check the Disable State Selection box e State selection must be completed with every download if the state selection is not disabled Add selection or the agent is licensed in less then 6 states Click on Connect to Humana e The state must be download to receive plan Click on state data Click Add Once completed click OK State Selection Select State s KS KY UEN aa Tr Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only T 10 01 2012 Connect to Humana cont Error Messages In order to get plan data and the zip code tables you MUST have an active licenses listed in Solar Without It you may get one of the
31. selection is made to receive Advocacy and Volunteer Information on Yes ld like to receive information about please check all that apply _ Opportunities to volunteer in community activities L Pending state or federal legislation Future Products Yes Id like to receive information about these future product offerings when they are available please check all that apply Health insurance spending account _ Travel Insurance Products Pet Insurance All ofthe above Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 117 07 23 2012 Member Authorization Form Review and Sign Office Use Only Plan Representative Agent Agent Dummy 11266 Read the consent statement to the nate member this explains how to cancel 6042010 Consent If at any time choose to cancel this authorization understand that must do sa in writing by sending my Mame Address Date of Birth and Member ID to Humana MarketPOINT P O Box 14706 Lexington KY 40512 4706 understand it s Humana s policy not to disclose my personal information to third parties except as permitted under the federal privacy laws Humana is required to let me know that should my personal information be disclosed to third parties the information may be redisclased and may not be protected by privacy laws Signature signature of applicant or authorized legal representati
32. signature of applicant or authorized legal representative incluaing valid Power of Attorney Legal Guardian ete Once the signature Is captured a Client Client Sign Signature Captured message will appear TE and the client s 2 ae 101200 Signature Date will automatically be entered into the field Click on the OK button to go to ee E the next step ok Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 110 07 23 2012 You will now be prompted to enter the Witness First Name Witness Last Name and Relation to Applicant in the fields under the witness signature Witness Translator Last Mame Witness Translator First Mame Pt pO Relation pO lf someone is acting as the POA that person will sign in place of the member and their personal information will need to be entered in the fields at the bottom of the application You as the agent are not the authorized representative If you are the authorized legal representative you must sign above and provide the following information Last Name First Mare tll po pO Address1 Address Doo y Doo City tate Zip DO J U ee ee Phone Relation to Applicant Pp GR BN VYerifler Verification Reason for not verifying When both signatures have been captured and the witness information has been entered in the appropriate fields you are ready to call for verification
33. solicit disenrolled members Failure to comply is a Violation of federal privacy laws and will result in legal action and disciplinary action up to and including termination 08 01 2009 02 01 2010 E l HumanaChoiceP FO Digital STYOMB4OFOSSNY Mak Sh igita aker arpie ROOR ONS Humana Sold Digital STYQMB4WOFDS7 TI Sub Way Choice PFFS H1804 485 Yes giz 1 2009 O82 1 2009 0901 2009 0203 2008 VPNDIOFOSO55 MAFD Humana Sold Digital STYOQMBSWOFDSHV4 Patterson Barbara Choice PFFS H180419 Yes OE 12009 O82 1 2009 08012008 0203 2008 Digital OTYOMB4WNKPZNDE Crane Scott Pa ana MAESE i Hom e3 C1014 Yes Mipi OB 22009 0901 2009 024 12008 Digital OTYQMBAWNKP2NSE Amos Tori HUMANA HONE Ee Yes OA 24N2000 08 24 2009 09401 2009 02 4 2008 01 07 2009 HOB23 01014 OF et Digital OTYQMB4WNKPZOOH Hunter Wayne cases ale Yes OS 24N2009 S24 2009 OOM 12009 02 20 2008 03 01 2008 H1806 001 Digital OTYOMBAXSO93110 Mapatested Gjaubhyi a HemanathoiceP PO R5g26 008 Yes O88 12009 08 31 2009 0901 2009 0220 2008 03012008 Sic SOMOS Timer Rebeca A eE Yes 04 21 2009 08 24 2009 09401 2009 02 19 2008 0318 2008 PPO Higos 7 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 137 07 23 2012 Reporting A report retrieval option has been added to the MAPA Workbench 1 2 3 4 J 6 T 8 Run the report Close the report retrieve the report at a la
34. v Some individuals may have other drug coverage including private insurance TRICARE federal employee health benefits coverage VA benefits or state pharmaceutical assistance programs Will you have other prescription drug coverage in addition to this plan for which you are applying If yes please list your other coverage and your identification IC number s for this coverage Mame of other coverage Policy for this coverage ID for this coverage rs Confidential and Proprietary to Humana Inc Humana Internal Use only 16 The PPO plan to the left will ask about group health coverage end stage renal disease and additional prescription drug coverage Again changes to future plans will cause this section to change as needed For Training Purposes Only Not CMS Approved 07 23 2012 Payment Tab Group Application If the plan you selected does not have a premium amount the tab will not open This section is requesting information on how plan payments will be handled Select the appropriate Payment Option and continue to the next section Monthly Premium Your Monthly Payment for your Humana Plan will be no more than Please select a premium payment option You can pay your monthly plan premium and or late enrollment penalty by mail using a Coupon Book Electronic Funds Transter or Automatic Credit Card Charge You can also choose to pay your premium and or late enrollment penalty by automatic
35. 1316 Montgomery Road Humana Guidance Center W thi ciate aran areal 61 12100 E Colonial Dr be 215 Englewood Road Suite A Insphere 7 3189 W Vine Street 7945 Harlem 5943 E McKellips Rd Ste 106 6975 W Charleston Blvd 7915 N Hale Ave Affinity Partner Humana Guidance Center 62 7400 Gall Blvd Affinity Partner Location ld 69 1915 SNOW ROAD 4438 Western Avenue 2025 W Henderson Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 126 07 23 2012 Free Standing Benefits Source Information Tier 1 What was the original source of the lead how did the client learn about Humana e Medicare campaign seminar ad e TIPS campaign seminar ad e Veterans campaign seminar ad etc Tier 2 Where they heard about the plan DMS call HGC WLMT Veteran Referral Self Referral etc Location e where the application was completed e may not be where the lead was sent which would be Tier 2 e In home appt was scheduled but directed to WLMT for convenience etc Source P nal What was the source for ihis sale Tieri Select Source v Ter Salact Soue Ahal was he location for this sale oleae Location K Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 127 07 23 2012 Free Standing Benefits FSB Proposed Effective Date Bove Dental C550 DHMO effective dates are calculated as f
36. 55 5555 OB 10 15 1935 Member ID Number As listed on your Humana Identification card DO Medicare Claim Number fF Email addresses if available will be used as a means to communicate various Humana related informatio Ls Mailing Address 1 lf different from permanent address om oO z y i am Re enter Medicare Mailing Address 1 Mailing Address 2 City state fip Code Oooo p 6 Hospital Insurance Part A A Only enter a mailing address if it is different Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 91 07 23 2012 Abbreviated Enrollment Form AEF Monthly Fromma Your hlanthly Payment for pour Humana Pian il be no more than A payment option must always be selected even if the premium is Zero Ploace select premium payment opion fou can pay your monthly plan premium of late enrollment penalty by mail using a Coupon Book Electronic Funds Tran fer o Automatic Creda Card Charge You can alea choose l pay your pr mem i late enrollment penally by automatic d educten fram your Social ecwily Check each monilh if you quality for exira help eth your Medicare predtngdinen plan Covurage Coss Medicare wall pay al oe parj of our plan preterm Medicare pays only a portion of thg paeme wee eal bill pow fer ihe around thet Medicare dopt nol cover Payment Options Social Security Benefit Check Deduction Railroad Retirem
37. 615 2257s 108th Street West Allis Wi Health Plan Senices 0616 227 Willow Bend Crystal MN 10617 11316 Montgomery Road Cincinnati OH Healthy American 10618 7666 Nob Hill Road Tamarac FL Hershend Fam Entertainment 0619 12100 E Colonial Dr Orlando FL Humana Guidance Center W 0620 215 Englewood Road Suite A Kansas City MO Indiana Farm Bureau 10621 3189 W Vine Street Kissimmee FL Insphere 10622 7945 5 Harlem Burbank IL 10623 59435 E McKellips Rd Ste 106 Mesa A 10624 975 W Charleston Blvd Las Vegas NV 10626 7915 N Hale Ave Peoria IL Affinity Partner 10627 7400 Gall Blvd Zephyrhills FL 17673 1000 N Green Valley Parkway Suite 720 Las Vegas NV Humana Guidance Center 17674 2025 W Henderson Columbus OH 17693 1915 SNOW ROAD PARMA OH Affinity Partner Location 7694 4438 Western Avenue Knoxville TN fe A 10614 711 W Wheatland Road Duncanville TX 10625 1000 N Green Valley Parkway Suite 720 Henderson NV Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 39 07 23 2012 Agent Only Tab Individual Application Products Discussed Please select ALL that apply This selection is used as a reminder for you It will write to the keywords section The products discussed should match your SCOPE Once you have completed all the fields click Save When saved the Application number will appear Click OK Once you have saved the information Review and Sign you are r
38. AL APPOINTMENT WILL BE LEFT ACTIVE WITH NO UPDATES ONLY MEY INFORMATION VVILL BE INSERTED Creating SOA without Application from existing contact ON calendar Woon UPLOAD MAPA will create an ACTIVE appointment as specified inthe s04 form MAPA will create link to SOA data in COS THE ORIGINAL APPOINT MENT WILL BE LEFT ACTIVE WITH NO UPDATES ONLY N EW INFORMATION WILL BE INSERTED Scenario 3 Creating BLANK 50A with Application Woon UPLOAD MAPA will create a DONE Appointmenton the date and time as specified in the SOA form MAPA will create an activity link to 504 policy link to SOA Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 26 10 01 2012 Eligibility Determination Individual Application A Eligibility Determination Please select a plan type Select the plan type the member wants to enroll in MAPD MA PDP The plan you select here will determine plans that you receive on the application Are you enrolling using a SEP pe Mote Click Yes to select SEF reason O Yes O No The zip code and County are only needed if YES is selected for the SEP The option will remained Gray if the selection is NO Zip Code z County SEP Reason Code Date of SEP event SEP Other CC Fan and PantB dates Hospital Insurance Part A Medical Insurance Part B D Date Of Birth These dates are taken from the Medicare card The dates and DOB will hel
39. Birth 40299 BULLITT KY 01 01 1936 Available Plans HurmanaChoicePPO H1806 001 Riders iw WY OPTION ENHANCED DENTAL wl WY OPTION VISION Last Mame First Mame Ml Buln Address 1 Address 2 APT City State fip County Phone 40299 BULLITT KY 502 555 5665 RYE HE Mailing Address if diferent fram Street Address Address 1 Address 2 APT City State Zip St E Email Address if available will be used as a means to communicate various Humana related information Optional Email Address Optional Preferred Method of Communication elephone Email Mail Person to notify in case of emergency nearest relative or friend Optional Last Name First Name MI Relationship To Applicant Phone a en Application Review continued on next page Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 43 07 23 2012 Application Review Individual Application The system has already scanned the application to ensure it was complete Medicare Health Insurance Last Name First Name NT ria E A Medicare Claim Number Re Enter Medicare Claim Medicare number is correct Please complete the information to the right 1734567004 1234567904 exactly as it appears on your Medicare card Effective Date Please contact Humana at 1 000 033 2367 TOD SEK Hospital Insurance Part A 1 077 033 4406 if you need information in another format or language than what is listed
40. Close the program Once you download this calendar wil show you any appointment you have on that day for the current month lt MAPA Workbench HUMANA Crus idan of when you need it most Application Type Language English Spanish i October 2011 Plan Type Sun Mon Tue Wed Thu Fri Sat Humana CarePlus 25 26 37 28 29 30 14 2 3 4 5 6 T 8 AEF Group Individual 9 10 11 12 13 14 15 OSB Member Authorization 16 17 E 19 20 21 22 SOA 23 24 25 276 27 28 29 FSB 2 3 5 Disable State Selection O REAL For Me at To A oS Medicare Supplement Today 10 18 2011 Oooo Singe Husband and Wit Comag Sou0ck sean M rma EEEE Tete ame Fema Mia OW Ei S a Su Authorization diam p Biew W515 West Lok leuiwdille KY Lre GONSE Campiei F55 Whale Flue 115 Wa aad Laeuaivillia KY H5 6555 Comghane Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 5 10 01 2012 Connect to Humana You will want to start and end your workday by Connecting to Humana so you can Synchronize updates back end tables and plan data Download pulls in the and agent information Upload takes completed applications and sends them to billing and enrollment MAPA Home allows you to check the status of applications The first step for synchronizing downloading and uploading information is to click Connect to Humana Disable State Selection
41. D Medicare Prescription Drug Plan PDP A stand alone drug plan that adds prescription drug coverage to the Original Medicare Plan some Medicare Cost Plans some Medicare Private Fee for Service Plans and Medicare Medical Savings Account Plans MW Medicare Advantage Part C Medicare Advantage Precription Drug Plans and other Medicare Plans Medicare Health Maintenance Organization HMO A Medicare Advantage Plan that must cover all Part A and Part B health care In most HMOs you can only go to doctors specialists or hospitals in the plan s network except in an emergency Scroll to the bottom and Click on Review and Sign sxe Review and Sign Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 23 10 01 2012 Scope of Appointment reload to create application Once you click Review and Sign the application will open to the signed page scroll to the bottom and click on the Create Application button Agent Sign Capture Signature Signature Date RSet ea parece Witness Sign Signature Date Signature of Vvitness Translator or Person assisting in completion of form other than agent VWitness Translator Last Name VWitness Translator First Name Relation pe ee lf you are the authorized Legal Representative POA you must provide the following information Last Name First Name Address1 Address2 City Zip Phone Relation to A
42. ENT OPTION If you have selected a plan with zero monthly premium and we determine that you owe a late enroll penalty we need to know how you would prefer to pay it You can pay by mail or Electronic Funds Transfer EFT each month You can also choose to Social Security or Railroad Retirement Board RRB benefit check each month Payment Options Social Security Benefit Check Deduction Railroad Retirement Board Benefit Check Deduction You must currently be receiving a Railroad Retirement Board benefit check in order to qualify fo Get a bill Electronic Funds Transfer from your bank account each month Depository Bank Name Routing Number Account Account Holder Name ii bes4 Sb 789 ts bcSNShPeALOL a ABA or apt bank account bank rowing aber Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 35 07 23 2012 Agent Only Tab Individual Application This section supplies information about the agent associated with this application Field Definitions Affinity Partner use the drop down arrow to select Affinity Partner Location only used if partner is Wal Mart or Guidance center would be store number Affinity TID This will pre fill wnen an affinity partner is selected Referring Agent only used if this was a broker referral must be added before app is signed Source and Sub Source for CDS refers to where the lead came fro
43. HGC WLMT Veteran Referral Self Referral etc Location e where the application was completed e may not be where the lead was sent which would be Tier 2 e In home appt was scheduled but directed to WLMT for convenience etc Source P nal What was the source for ihis sale Tieri Select Source v Ter Salact Soue Ahal was he location for this sale oleae Location K Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 38 07 23 2012 Agent Only Tab Affinity Partners Delegated agents only need to select NONE Office Use Only Affinity Partner Plan Representative Location REP Benne CH O Home Instead Senior Care Date Humana Guidance Center Affinity TID Referring Agent Agent as ie leary doan anon IG ceea ihe rate C bd Goes Balea oani aiueo he vord NONE Attachments 0 AmM001 AMO002 C AMO06 Affinity Partner lf the affinity partner is Wal mart or Humana WalMart w Guidance Center the store number must be Affinity Partner Location listed Search StorelD If you don t know e Store ID e Click on thgSearch Store ID button e Leave yank and click Search I EntegSiate and City of the store WalMart Was this Sale originated from a WalMart Store Store ID _ Leave Store ID Blank Was this Sale originated from a WalMart Store cy Lo STOREID ADDR1 Cry STATE 10613 g646 Skillman Street Dallas TH Health Plan One 10
44. Identification of Chosen Primary Care Physician PCP clinic or health center Loo S Goo E Are You an Established Patient of the Physician You Selected O Yes O No The PCP selection is optional but suggested for PPO aai PCP selection is required for HMO Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 33 07 23 2012 Payment Tab Individual Application If the plan selected does not have a premium amount a payment option still must be selected in case there is a penalty added to the plan This section is requesting information on how plan payments will be handled Select the appropriate Payment Option and continue to the next section You must have the same payment option for both the Humana plan and the rider Your Monthly Payment for your Humana Plan will be no more than 1131 00 Total Premium 155 00 Your Optional Supplemental Prerniurn 24 00 Please select a premium payment option SSA and or RRB deduction will not be an option if your total premium is greater than 200 You can pay your monthly plan premium and or late enrollment penalty by mail using a Coupon Book Electronic Funds Transfer or Automatic Credit Card Charge You can also choose to pay your premium and or late enrollment penalty by automatic deduction from your Social Security or Railroad Retirement Board Benefit Check each month If you qualify for extra help with your Medicare prescrip
45. If you are paying for the plan please provide the following information Then tell us how you would like to pay for the plan be paying for someone else s plan please also complete the Alternate Payor section below Last Name First Marne hdiddle Initial C a Address Panmanent Addess 2 Agt eee SSS Gily State iio posse ps Horne Phone Feguired Daytime Phone Optional ass Prarie Your Monthly Premium Movthly premiwm includes 0 75 association fee and 1 00 Administrative One time Enrollment Fee no able Your enrollment fee is waived Total initial Payrnent 115 74 Single Payment Option saves 12 Ayr Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 123 07 23 2012 Free Standing Benefits FSB Payment e Select payment option for billing cycle e There are only 2 payment options for the initial payment Credit card Electronic Transfer Note each option requires bank information Payment Options Please select payment option for your billing cycle and payment preference for your premium payment Annual Payment Monthly Payment Initial Premium Visa MasterCard Discover Credit Card Number Expiration Date Cardholders Mame aT i Depository Bank Mame Routing Murmber Account Number Account Checking Savings authorize Humana to draw premium payment and charges from my credit card account until this authorization is revoked
46. KY 40209 Fred 1515 west main Street louisville KY M29 G02 335 3333 Incomplete Jian We main street palm coast FL SMT 602 222 2007 Incomplete For Training Purposes Only Not CMS Approved Confidential and Proprietary to Humana Inc 07 23 2012 Humana Internal Use only 140 Deleting an Application You can delete incomplete applications that are stored on your laptop by clicking the application record this will highlight the record and make the Delete Application button accessible and then clicking on the Delete Application button You are never to delete a signed application Application Search searchBy All Complete Incomplete Clone App Load App Delete App D Type Last Name First Name Address City State Zip Phone Status MAPATESTED GL GWION DECATUR IN 46733 19 724 7438 Incomplete 1 Highlight the application needed and click Delete App Are you sure you want to Delete this application 2 Click yes 3 A message box will confirm the application has been deleted Click OK to close the message boxes Application Deleted Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 141 07 23 2012 Canceling an Application The cancel App button is only used for COMPLETED applications lf the member calls the agent to cancel before the agent has uploaded the application they are to mark it MAPA cancell
47. M T RL85JDH42KRG Monday Friday 8 a m 6 p m TDD for hearing impaired 1 800 833 3301 Member Name PUS Bunny Hour Precertfication 1 800 523 0023 Proposed Effective Date 04 01 2009 Doctor and Hospital Preadmission certification is required for Enter name of OSB plan all nonemergency and nonurgent services for HMO plans however it is requested for PPO and PFFS plans Providers can call Provider Relations at 1 866 291 9714 for PCP Phone if applicable _ Number of HMO dentist PFFS plan terms and conditions Copayment PCP Specialist ER Medicare Plan GR __ 496 73 py Plan PCN 03200000 BN 001 BN 610649 03 02 09 Application ID Number Plan Name Primary Care Physician PCP Dental HMO dentist name _ Rebecca Boston 03 02 09 Bugs Bunny Agent Signature Date Member Signature Date GN85023DRR 0206 Medicare approved HMO PPO PDP and PFFS plans Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 144 10 01 2012 Troubleshoot MAPA What is Troubleshoot MAPA Many times agents are not able to perform various operations through MAPA such as Upload applications download etc The Troubleshoot option in MAPA will resolve all such issues It will also fix missing database objects or issues related to troubleshoot Troubleshoot will not erase any data from agent s machine When to Troubleshoot MAPA Troubleshoot option can be used while agents are facing
48. Materials Mo Seminars Available for Location Selected Member has already attended Please select the materials you would like to receive by email instea a ber Undecided p note that you must register on MyHumana com once you ve received your ID cards and enrollment confirmation in order to begin receiving selected mate _ SS er regardless of your selections below Medical Dental Explanation of Benefit or Smart EOB C Annual Notification of Change and Evidence of Coverage Cental Explanation of Benefits EQB C Your Smart Summary Notification of Request for Other Insurance Materials Used MU MAPD Power Point Presentation C MA Power Point Presentation POP Power Point Presentation C Summary of Benefits C Value Added Services C Let s Talk Brochure Benefit and Provider Leaflet C Compensation sheet Comments Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 45 07 23 2012 Capturing Signatures Client After your client or someone acting as the Power Of Attorney POA for the client has read and understood the summary of the selected plan obtain a signature Click in the circle next to Client Sign to activate the signature pad Signature signature of applicant or authorized legal representative including valid Power of Attorn Capture Signature O Witness Sign signature Date Clear Signature Signature
49. Medicare card Some fields will not allow data entry unless their section requires information lf the client does not have Medicaid you would leave the choice as No You would not be able to enter information into the Medicaid box unless you selected Yes as the answer to the Medicaid question Note For nursing home if yes Date refers to the date the client entered the facility Last Name First Name z Medicare Claim Number Re Enter Medicare Claim Please take out your Medicare card to complete 1234567 094 s 1234567094 this section Please fill in these blanks so the I z 5 A ener tad shits and bine Mea nat Effective Date Medicare Claim Number is required It is entered twice for validation Dex Hospital Insurance Part A Medical Insurance Part B Male Female 1001 2011 10 01 2011 Contract Number PEP Language Preference for Member Services mons C Ers J Please contact our Member Services Department at 1 600 794 5907 if you need information in another format or language We are open F days a week from o a m to p m From February 15 until the following Annual Election Period AEP you may leave a voice mail messane after ho aturda 3 j and we will re i Are you enrolled in your state Medicaid program If Yes Medicaid Medicaid Effective Date Are you a resident in a long term care facility such as a nursing home Yes No yes please provide the following informatio
50. OK your application list until you complete an upload process at which time it will be removed Type Last Mane First Hame Alibre City Zip Phone Shanes SOA crakes cheasa 1595 willow va loubeville KY 407 602 266 4868 Complete FSE the labs Pe 114 warlock sheet lou bevel be KY 40299 GOAIA Complete SDA candy baal 1515 weet main loutevilte KY W C7466 Tesi 1515 deg lana joutoville BY eo So 460 66 Cm A F FSA 4 pT AE Fogga Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved 25 07 23 2012 Humana Internal Use only Scope of Appointment Below are situations that will help you with the SOA process so that they know WHEN to make manual corrections changes updates for current those appointments left active in CDS Scenario 1 ee Creating SOA from Existing Contact with Application NWOT on calendar Upon UPLOAD MAPA will create a DONE appointment onthe date and time as specified in the Scope of appointment form An activity willbe created that links tothe SOA Policy will link to SOA Creating SOA without Application from existing contact Woon Upload MAPA will create an ACTIVE appointment as spectied on the SOA form with link ta SOA data Scenario 2 Creating SOA with Applicaton from existing contact ON calendar Woon UPLOAD MAPA will create DONE appointment on the Date Time as specified in the SOA form MAPA will create an activity link and policy link to the SOA form The ORIGIN
51. Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 52 07 23 2012 Medicare Supplement Application Application Type Language MAPA allows you to write GaN di inati i Plan Type an application for a Single person yI H umana CarePlus or a Husband and Wife at the same time AEF Group Individual OSB Member Authorization O 50A O FSB REAL For Me Medicare Supplement Single Husband and Wife This function has been disabled Click Create Blank App for a new client Contact Search Appt Time Last Name First Name Address City Phone Jul 27 2009 1 00PM DEW BOBBY 2330 ORANGEWO DURHAM 9194 383 5075 Create Blank App Jul 27 2009 4 00PM_ MONEY LOMA 632 PIPERS GAP RD MOUNT AIRY 336 786 4622 Jul 27 2009 8 00AM Test Bear 110 Beal St Bardstown 502 348 367 If you create a blank application for a client that already exist in your system you WILL create a duplicate record Once enrollment type selected you will get the Rate calculator to see if the client is eligible A Rate Calculator Humana Insurance Company of Kentucky 2432 Fortune Drive Lexington KY 40509 Zip Code 40299 County BULLITT KY State KY Medical Insurance Part B Effective Date Date of Birth Gender O Male Female Available Plans Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 53 07 23 2012 Med
52. Use only 49 07 23 2012 Verification Outbound verification is the only method available When completing an in home application advise the member that Humana will be calling in a few days to complete the verification Prepare member for call 0B This default will automatically be selected New Member Orientation New member orientation will go into more detail about how to use your plan and give valuable info on different programs that we have select Yes or No If no you must use the drop down and select a reason why This will write to the Smart Pad in CDS NMO New Member Orientation Reason for not attending MMO Would vou like ta attend NMO Yes No Mot Interested Mo Seminars Avallable for Location Selected Member has already attended Member Undecided Other Selecting Yes will not enroll the member in an orientation class Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 50 07 23 2012 Saving the Application To ensure your application signature is Saved you must hit the Save and Close bution located at the bottom of the application If you click the X in the upper corner the signature will not save Click on the Save and Close button to save the application lf you make a mistake or forget something on the review and sign page you will see the error box showing what corrections need to be made Application Update
53. an begin correcting the application Effective Date Hospital Insurance Part Aj Errors on all the sections will be highlighted with o a red background As you correct the error the red Medical Insurance Part B highlight will disappear Once the errors have been corrected the program will prompt you to Save the Application Before Continuing Click the Save button to save the application then click the OK button to continue to the signature section Save Application Please Save Application Before Continuing Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 41 07 23 2012 Service Agreement Individual Application e The online service agreement must be read by or read to the member e This states they understand everything is being completed electronically They agree to the terms and conditions If the member does not agree to the Service Agreement you must complete a paper application Agreement A Online Service Agreement Agreement with Humana This agreement is between you and Humana Inc on behalf of its affiliates Consent to Electronic Transactions the User and Humana acknowledge and agree to the following provisions 1 To conduct this enrollment and any changes made to this enrollment information through the use of an electronic transaction which will be verified by the use of an electronic signature 2 This consent to con
54. ando FL 0620 215 Englewood Road Suite A Kansas City MO 10621 3189 W Vine Street Kissimmee FL 10622 7945 Harlem Burbank IL 10623 5943 E McKellips Rd Ste 106 Mesa A 10624 975 W Charleston Blvd Las Vegas NV 10626 7915 N Hale Ave Peoria IL 10627 7400 Gall Blvd Zephyrhills FL 17673 1000 N Green Valley Parkway Suite 720 Las Vegas NV 7674 2025 W Henderson Columbus OH 17693 1915 SNOW ROAD FARMA OH 17694 4436 Western Avenue Knoxville TN 0614 T11 W Wheatland Road Duncanville TX 10625 1000 N Green Valley Parkway Suite 720 Henderson NV For Training Purposes Only Not CMS Approved 07 23 2012 STATE service Agreement Group Application e The online service agreement must be read by or read to the member e This states they understand everything is being completed electronically They agree to the terms and conditions If the member does not agree to the Service Agreement you must complete a paper application Agreement A Online Service Agreement Agreement with Humana This agreement is between you and Humana Inc on behalf of its affiliates Consent to Electronic Transactions the User and Humana acknowledge and agree to the following provisions 1 To conduct this enrollment and any changes made to this enrollment information through the use of an electronic transaction which will be verified by the use of an electronic signature 2 This consent to conduct an electronic transaction only applies to enrollmen
55. anslated or a witness was present for the signature of the client signature signature of Applicant or Authorized Legal Representative including valid Power of Attorney Legal Guardian etc signature Date g Capture Signature Ss Date aE ree oan Date Signature of Witness Translator or Person assisting in completion of form other than agent signature Date Clear Signature Witness Translator Last Mame Witness Translator First Marne ee Return To Application Save and Close Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 131 07 23 2012 Review and Sign Power Attorney signing the application e must provide demographic information for them e They must send supporting documents to billing and enrollment to stay in the plan If you are the authorized legal representative POA you must sign above and provide the following information Last Name First Mame Mil Address Address Z Po City state Zip Po Phone Relationship to Applicant Po You will be receiving a request for supporting documentation upon your enrollment This supporting documentation is required in order to remain on the plan The FSB application allows the upload to be delay Upload must be completed before effective date Optional Upload Delay _ Upload Delay EffectiveDate 08 01 2011 _ Please enter date for application upload L Example
56. ber will come from the Members Humana card This is not a required field This number must match the Medicare l Card Enter it twice for validation Re enter Medicare Number Preferred Method of Communication Telephone Email Mail How the members wants the agent to contact them Optional Email addresses By providing this address you are giving Humana permission ta send non enrallment materials via email If mailing address is the same as Residential Check the box If the mailing address is different then the Residential Mailing Address address add the address Never us NA ts this field C Check here if the Mailing Address is the same as the Residential Address Mailing Address 1 Mailing Address 2 City state Zip Code Hospital Insurance Part Medical Insurance Part B Ot ft Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 101 07 23 2012 Optional Supplemental Benefit Enrollment Form Monthly Premium Your Monthly Payment for your Humana Plan will be no more than 222 00 The system will calculate both the Humana plan rate and Your Optional Supplemental Premium 22 00 the OSB rate together for one deduction Your total monthly payment will be no more than j244 00 Please select a premium payment option You can pay your monthly plan premium by mail using a Coupon Book Electronic Funds Transfer or Automatic Credit Card Charge Y
57. by me e Subsequent payment can be made differently then the initial e Make selection and enter information required e f payment is the same select same box every thing will pre fill Same as Initial Payment O visa O MasterCard O Discover American Express Credit Card Number CW Expiration Date Cardholders Name EE ee E Electronic Funds Transfer Depository Bank Mame Routing Number Account Number 112233445 2522111111122233 Account Checking Savings Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 124 07 23 2012 Free Standing Benefits FSB Agent Only Plan Representative e Writing agent e Information will pre fill Wiiting Agent Producer Flan Representative Boston Rebecca O Career Agent Representative Number 1407605 Delegated Agent MECA Agent e Affinity Partner campaign and Affinity TID will pre fill if downloaded contact e f no affinity partner select None e Disposition 1 will be FSB e Disposition 2 why they wanted the FSB e Disposition 3 depends on disposition 2 and not always needed Agent Info Date Location Affinity Partner Campaign Affinity TID oz jf Benefit Protect v 0302047632 _v 20 1577297 Referring Agent Referring Agent Nurnber Affinity Partner Location Source SUB Source House Member Referral General Client Referral Type Sub Type a Disposition sold FSB k Disposit
58. c Humana Internal Use only Addresa ay 1515 haai Box k lonhevllee 1515 willow id wailock sthee diii diiplels For Training Purposes Only Not CMS Approved 17 10 01 2012 Scope of Appointment The SOA is in pending application status and does not upload until the following is true If the application is not completed from the Scope of Appointment The agent will log back into the system and add Application ID Date Appointment completed Plans agent represented lf the application is created from the Scope of Appointment the appointment information will pre fill into the completed scope Application ID Date Appointment completed Plans agent represented Date of Birth Medicare ID number When these fields are completed the Medicare ID and Date of Birth become required To be Completed by the agent after the scheduled appointment Application ID Number Date Appointment Completed Po 7 L Did not enroll Plan s the Agent Represented L Appointment not completed Medicare Claim Number Re Enter Medicare Number Date Of Birth MM DD YY YY Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 18 10 01 2012 Scope of Appointment Initial Method of Contact Unexpected additional attendee v Use drop down to select initial Method of contact Medicare Claim Number Re Enter Medicare Number 1234567094 1234567094 In MAPA you have the
59. c For Training Purposes Only Not CMS Approved Humana Internal Use only 97 07 23 2012 New Member Orientation New member orientation will go into more detail about how to use your plan and give valuable info on different programs that we have select Yes or No If no you must use the drop down and select a reason why This will write to the Smart Pad in CDS NMO New Member Orientation Reason for not attending MMO Would vou like to attend MMO ee select Reasor Yes Ono o O E Mot Interested Mo Seminars Available for Location Selected Member has already attended Member Undecided Other Selecting Yes will not enroll the member in an orientation class Materials Used select all the materials that you used during your Appointment This information will write to the Smart Pad in CDS Materials Used MAPO Power Point Presentation MA Power Point Presentation POP Power Point Presentation Summary of Benefits Walue Added Services Benefit and Provider Leaflet Compensation sheet Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 98 07 23 2012 Optional Supplemental Benefit Enrollment General information on what form to use and when lf the agent is enrolling the member in both the MA plan plus OSB at the same time and this is the member s first enrollment Individual form is used lf agent is enrolling the membe
60. ccepted and you answered MO to both questions you qualify for the Preferred rates Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 54 07 23 2012 Medicare Supplement application New Questions added to Rate Calculator Jf FL KY NH PA TN WA and WI will have the BMI questions displayed in the Medical Questions section ONLY and are ONLY enabled and required outside of open enrollment and guaranteed issue All other States not mentioned above will display in the Premium Determination Section and will ALWAYS be enabled and required of NOTE The following states will NEVER display the BMI questions CT MA NY VT w Rate Calculator Humana Insurance Company of Kentucky 2432 Fortune Drive Lexington KY 40509 Please list any presonption drugs full PRC CaO mame pou are Currently taky or have taken wahin the past 12 months H you are not currently taking nor have you taken any medications within the past 12 monlis please waite NONE Height ft Height fir Weight bs Bhil How to enter BMI 1 Enter height in feet only 2 Enter height in inches only 3 Enter weight BMI will automatically calculate Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 55 07 23 2012 Medicare Supplement application Once your Zip and Plan are set Fill out the questioner depe
61. ct lines of plan business include Medigap MA and PDP products If another type of Medicare product needs to be discussed at the request of the beneficiary during your appointment a second scope of appointment form must be completed At this time you can use the SOA form located on the MAPA workbench page Remember 1 A beneficiary can not agree to the scope over the phone unless it is recorded and then sign the form at the beginning of the sales appointment 2 When using the paper scope of appointment form it must be completed and returned prior to the appointment EFFECTIVE IMMEDIATELY if an agent can not execute a SOA in advance of the appointment and must have the beneficiary sign the SOA at the start of the appointment the agent must also note on the front of the SOA form the reason why The note must be initialed and dated by the agent 3 A beneficiary may sign a scope of appointment form at a marketing presentation for a follow up appointment Use the SOA on the MAPA workbench The 48 hr rule will not apply at this time 4 In the instance where a beneficiary visits a plan sponsor or agent office on his her own accord the plan sponsor or agent should complete a scope of appointment form and secure the beneficiary s signature prior to discussing any plans Use the SOA on the MAPA workbench The 48 hr rule will not apply at this time 5 During an in home appointment a Scope of Appointment is needed for everyone interes
62. d Save and Close a Enpi i l Errors have been found Please correct before signing Check the following Signature information 1 Witness Last Name Required 2 Witness First Name Required 3 Witness Relation Required Check the following Verifier Information 1 Provide Verification information or Reason for not verifying A message box will indicate the Application 6MTRL85JDH42KRG Successfully Saved application has been saved Your application is now completed Once you click OK you will return to the MAPA Workbench Confidential and Proprietary to Humana Inc Humana Internal Use only For Training Purposes Only Not CMS Approved 51 07 23 2012 Saving the Application A Test application box has been added to all applications Check marking this box will keep the application from fully uploading ApplicationID Application SC7TV7C3QFIK27HC Successfully Saved The Test application will appear in your application list until you complete an upload process at which time it will l Check here if this is a test application be removed OK Type Last Hame First Hame Buhh ems City State Zip Phone Stahes ARA erakar chiara 1515 willow rad loukeyville KY 9 Gl 2666666 Conmplete FSB the labs wiliam 114 warkeck sheet Jouke EY 40299 G0 Complete SHA candy banal 1515 weet main ontevilte KY iira MAbs Te ies 240 460 Can FSB pha Fhmgg n 15145 deg lana louinville AY Confidential and
63. d Enrollment Form Source Information Tier 1 What was the original source of the lead how did the client learn about Humana e Medicare campaign seminar ad e TIPS campaign seminar ad e Veterans campaign seminar ad etc Tier 2 Where they heard about the plan DMS call HGC WLMT Veteran Referral Self Referral etc Location e where the application was completed e may not be where the lead was sent which would be Tier 2 e In home appt was scheduled but directed to WLMT for convenience etc Source P nal What was the source for ihis sale Tieri Select Source v Ter Salact Soue Ahal was he location for this sale oleae Location K Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 93 07 23 2012 Abbreviated Enrollment Form AEF Heview and Sign When you click Review and Sign the system will review the application looking for errors if found you will get the error page and need to correct them before you can move on ES Error Errors have been found Please correct before signing Please fill Following field s in Demographic page before saving 1 Last Name is Required 2 First Name is Required 3 PartA Date is Required 4 PartB Date is Required GS Agreement A Online Service Agreement Agreement with Humana This agreement is between you and Humana Inc on behalf of its affiliates Consent to Electron
64. deduction from your Social Security Check each month Ifyou quality for extra help with your Medicare prescription plan coverage costs Medicare will pay all or part of our plan premium lf Medicare pays only a portion of this premium we will bill you for the amount that Medicare does not cover Payment Options O S54 Coupon Book redt Card Name O Visa O MasterCard Discover Card Number Expiration Date Automatic Withdrawal Bank Name Routing Number Account Number Account Type T i pur Hame 1001 Checking savings 1264 Oak Armytowm USA EEEE 20 PAY TO THE Social Security CIROER OE DOLLARS Automatic deduction from your monthly Social Security benefit c deduction may take two or more months to begin In most cases Social Security benefit check will include all premiums from your FOR to the point withholding begins 2h23Q5G789 2 COORZ34K56789 100 Account Humber ABA Check Routing Number Check 000k 34 56789 L234 56789 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only T1 07 23 2012 Agent Only Tab Group Application Affinity Partner always select None Affinity Partner Location not used for a group application Referring Agent not used for group applications Source and Sub Source for CDS refers to where the lead came from House Member use to determine head of house or spouse for CDS use Ty
65. duct an electronic transaction only applies to enrollment services 3 That may request that this Agreement be terminated If terminated paper access to enrollment services and forms will be distributed at no cost to me if an address phone number and a contact name are provided to a Humana representative 4 That may request a paper copy of this recorded transaction 5 To be bound by this agreement as stated by law throughout the term of this Agreement 6 This agreement may be modified at any time if Humana provides notice ave the member put a check in For More Information Then click AGRE Humana 500 W Main Street Louisville K lop checking this box you acknowledge you have reag and understand the above information as Once the agreement is completed you will be taken to the Review and Sign page Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 42 07 23 2012 Application Review Individual Application When the program recognizes that the pad is connected to the laptop the program will then display a Summary page listing all the information that has been entered on the application Scroll through the application and review the accuracy of the information with the client You are reviewing the application for spelling errors and incorrect information a Individual Application Review and Sign Client Information fip Code County Date Of
66. e At the end of your day when you upload completed applications disposition and update contact information from the laptop to the server Note If you have any difficulty with the MAPA program during a sale complete a paper application at that time and contact CSS after your sales call Do not contact CSS during your sales call CSS 888 224 2700 Louisville 800 435 7661 Green Bay Enrollment Department 800 992 2551 Agent Support 866 921 6245 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 3 10 01 2012 Log in First time users will be instructed to create a MAPA user ID and password SS L z New User Instructions ES WELCOME As a New User to the MAPA Application you are asked to provide a User Name Login and Password in order to securely access the program and its Functionality Please note that the Following rules apply to the creation of your User Name Login and Password 1 The First Character MUST be a Letter of the English Alphabet 2 They MUST be ak least 6 characters and no more than 12 in length 3 The Password MUST contain ak least 1 numeric character 0 9 4 The Password MUST contain at least 1 of the Following or 5 The Password CANNOT contain your User Name Login value 6 They CANNOT contain any Spaces before after or inside IF you should have any questions please call 1 G00 SM4 MeEs whe
67. e The agent can click the clear witness signature button Once the witness signature is captured a Witness Signature Captured message will appear and the witness Signature Date will automatically be entered into the field Click on the OK button to close the message box Capture Signature sities Signature Date Clear Signature Witness Sign Witness Signature Captured signature of Witness Translator or person assisting in completion of form other than plan representative Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 85 07 23 2012 You will now be prompted to enter the Witness First Name Witness Last Name and Relation to Applicant in the fields under the witness signature Witness Translator Last Mame Witness Translator First Mame Pt pO Relation pO lf someone is acting as the POA that person will sign in place of the member and their personal information will need to be entered in the fields at the bottom of the application You as the agent are not the authorized representative If you are the authorized legal representative you must sign above and provide the following information Last Name First Mare tll po pO Address1 Address Doo y Doo City tate Zip DO J U ee ee Phone Relation to Applicant Pp GR BN VYerifler Verification Reason for not verifying When both signatures have been captured and
68. e message box Capture Signature sities Signature Date Clear Signature Witness Sign Witness Signature Captured signature of Witness Translator or person assisting in completion of form other than plan representative Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 70 07 23 2012 Capturing Signatures Witness You will now be prompted to enter the Witness First Name Witness Last Name and Relation to Applicant in the fields under the witness signature VWitness Translator Last Mame Witness Translator First Mame PO po Relation pt lf someone is acting as the POA that person will sign in place of the member and their personal information will need to be entered in the fields at the bottom of the application You as the agent are not the authorized representative If you are the authorized legal representative you must sign above and provide the following information Last Name First Mame tll po pO Address Address2 po pO City tate Zip po l Phone Relation ta Applicant pO GR BN W prifier Verification Reason for not verifying New Member Orientation New member orientation will go into more detail about how to use your plan and give valuable info on different programs that we have select Yes or No If no you must use the drop down and select a reason why This will write to the Smart Pad in CDS
69. e signature Is captured a Client Client Sign Signature Captured message will appear TE and the client s 2 ae 101200 Signature Date will automatically be entered into the field Click on the OK button to go to ee E the next step ok Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 47 07 23 2012 Capturing Signatures Witness Usually a witness signature will not be necessary for the application Some situations where a witness signature would be captured are when e The applicant wishes for someone else family member friend to sign the application as a witness e The applicant cannot physically completely sign their name i e they sign an X on the tablet By clicking the Witness Translator Sign radio button the Capture Client Signature and Clear Client Signature buttons change to Capture Witness Signature and Clear Witness Signature respectively The signature tablet is ready for the witness signature If the witness does not like the appearance of their signature they can try again after the signature on the tablet screen is cleared The signature can be cleared in one of two ways e Tab clear on the signature pad e The agent can click the clear witness signature button Once the witness signature is captured a Witness Signature Captured message will appear and the witness Signature Date will automatically be entered
70. eady to Review and Sign Referring Agent Every time you click Review and Sign you will be asked about entering a Referring Agent This is only used for Do you want to enter Referring Agent Broker referrals Every time you click Review and Sign you will be asked if this sale originated from WalMart If Yes enter the store ID storeID C If No leave ID blank and click no Was this Sale originated from a WalMart Store Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 40 07 23 2012 Review and Sign Errors lf you have not connected your signature tablet to your laptop the program will prompt you to do so at this time When it is time to sign on the tablet screen use the attached stylus DO NOT USE AN INK PEN ON THE PAD When you click on the Review and Sign button the jam program reviews the information on the application Errors have been found Please correct before signing and creates a list of items Following field s in Plan Specific tab has error s that need to be corrected 1 Cartier Name for the application to be Following field s in Office Use tab has error s accepted 1 The Effective Date must be between 11 01 2008 and 12 01 2008 lf there are errors a window will appear listing the errors that need to be corrected before continuing to the next section Clicking on OK will take you to the first section with errors so you c
71. ed which passes an error code to Enrollment Click on the application you want to cancel Then click the Cancel APP button Application Search SearchBy All C Complete C Incomplete Clone App Load App Cancel App a Phone Status Incomplete comp ete Louisville 11999 W Complete me Last Name First Name Address City State btamond 1515 Willy street io Are you sure you want to Cancel this application You will have to select YES to Confirm you want to cancel this application Once you say YES the application is canceled Application Cancelled The status will change to MAPA cancelled And upload as a cancelled application Application Search Search By Al C Complete C Incomplete orem as E ca City Lip Status Phone Last Name First Name Address Type Individual fefe efere KY 40220 incomplete Individual River Swanny 212 River Rd Louisville KY 40249 222 222 202 MAPA Cancelled Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved 142 07 23 2012 Humana Internal Use only Member Receipt All the information you need to complete the receipt is on the application this receipt is used when you write a MAPA or Fast APP application NEVER add PHI e g SSN DOB information to a receipt Temporary Proof of Membership Humana Medicare Plans in Humana s Medicare Plans New Membe
72. enrolling using a SEP m Mote Click Yes to select SEP reason gt Yes gt No The zip code and County are only needed if YES is selected for the SEP The option will remained Gray if the selection is NO Zip Codes lt s County SEP Reason Code Date of SEP event SEP Other CC Fan and PantB dates Hospital Insurance Part A Medical Insurance Part B D Date Of Birth These dates are taken from the Medicare card The dates and DOB will help determine the election period options you receive _ jan e ct a I ilal I yE 2011 From Jan 1 thru Oct 15t the plan 2012 The plan year only needs to be selected from Oct year will be greyed out 15t thru the end of Nov Determine Eligibility Click here to get election period options Select an Election Period if not enrolling using a SEP ICEP IEP SEP AEP OEPI Proposed Effective Date Once you have the information completed click Determine Eligibility andthe system will activate the election codes that are available Select the correct election period and click continue eomme Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 89 07 23 2012 Eligibility Determination AEF lt Eligibility Determination Please select a plan type MAPD O MA O PDP Selecting YES requires the county Zip code and Sep reason code Are you enrolling using a SEP Yes Mote Click Yes ta select SEF reason lt g
73. ent Board Benefit Check Deduction You must currently be receiving a Railroad Retirement Board benefit check in order to qualify for this payment option Coupon Book Credit Card Name O Visa MasterCard ES Discover Card Number Expiration Date Electronic Funds Transfer Select how they want to pay for the plan Bank Name Routing Number Account Number For ts 223456789 05 223456789103 a 1026 ABA or bank routing number Account Type Checking Savings Office Use Only Old Plan GR BN Current Plan GR BN GR GR 235451 235464 BN BN Plan Representative REP Affinity Partner 1407608 Select A Partner i Date Location Campaign Affinity Partner Location 07 28 2009 fs05046921 C i Referring Agent Agent a 9 Source Type Sub Type 3 4 Disposition Disposition 2 Disposition 3 Select A Disposition Disposition not available Y Disposition not available v ICEP IEP SEP AEP OEPI Proposed Effective Date 17 07 2010 Products Discussed Please select ALL that apply DEN C Other CO MA MAPD C PDP C MedSupp Disposition the 3 tiered disposition resembles the new CDS version In disposition 1 select the correct sold product Then select reasons for enrolling under disposition 2 and 3 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 92 07 23 2012 Abbreviate
74. ent Only Client Information Zip Code County Social Security Nurber Optionall Date Of Birth Available Plans Re enter SSN Select a Plan v Last Name First Name Ml e Address 1 Address 2 APT 1212 River Rd Po City state Lip County Phone Ky 40099 BULT KY 0222222222 CEHA a Mailing Address if diferent from Street Address Address 1 Address 2 APT Doo G O City state Lip Email Address If available will be used as a means to communicate various Humana related information Optional a Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 139 07 23 2012 Copy an Application Copy Application will allow an agent to create one application and auto fill a different application with the data Note The review and sign page will not copy Steps 1 Select the member application to copy 2 Click on the new application type to complete 3 Click Copy App Application Type Language C Spanish Connect To Himani n 5 P Group Indbvidiral Ext MAPA ane s 4 E _ Member Authorization S FSB O REAL For Me Es ire Supplemen singla Husband and Wife i a ey Cancel App ip Phone Status Hold Status 40289 002 666 555 Complete 502 466 5606 Incomplete Application Search Searchiy Gab t 1575 dint lane loulsville 1515 disney lane louisville
75. entered Affinity Partner Health Compare Health Flan One Health Flan Services Healthy American Hershend Fam Entertainment Humana Guidance Center W Indiana Farm Bureau Insphere Affinity Partner Humana Guide Affinity Partner Location le Confidential and Proprietary to Humana Inc Humana Internal Use only 103 STOREID ADDR1 CTY 10613 g646 Skillman Street Dallas TH 10615 2257 S 100th Street West Allis WI 40616 227 Willow Bend Crystal MN 0617 11316 Montgomery Road Cincinnati OH 10618 T666 Nob Hill Road Tamarac FL 10619 12100 E Colonial Dr Orlando FL 0620 215 Englewood Road Suite A Kansas City MO 10621 3189 W Vine Street Kissimmee FL 10622 7945 Harlem Burbank IL 10623 5943 E McKellips Rd Ste 106 Mesa A 10624 975 W Charleston Blvd Las Vegas NV 10626 7915 N Hale Ave Peoria IL 10627 7400 Gall Blvd Zephyrhills FL 17673 1000 N Green Valley Parkway Suite 720 Las Vegas NV 7674 2025 W Henderson Columbus OH 17693 1915 SNOW ROAD FARMA OH 17694 4436 Western Avenue Knoxville TN 0614 T11 W Wheatland Road Duncanville TX 10625 1000 N Green Valley Parkway Suite 720 Henderson NV For Training Purposes Only Not CMS Approved 07 23 2012 STATE Optional Supplemental Benefits Source Information Tier 1 What was the original source of the lead how did the client learn about Humana e Medicare campaign seminar ad e TIPS campaign seminar ad e Veterans campaign seminar ad etc Tier 2
76. eoarthritis are you currently taking test drug or not sure 2 You must list all drugs for the SNP Please list your Primary Care Physician Mame Address City State ip Phone Kn Please list any specialist physicians yOu see regularly 3 Only one physi f ian is needed but you may add bc th Address PO Phone en Return to Eligibility Determination Click next to continue on Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 32 07 23 2012 Plan Specific Tab Individual Application This section is requesting information for the particular plan the client has selected With the numerous plans the specific options for each will look different on the screen Demographics Medicare Card Clinical Qualifying Plan Specific Payment Agent Only For example the PDP form to the right asks if Some individuals may have other drug coverage including private insurance TRICARE federal employee health benefits 4 the client has coverage YA benefits or state pharmaceutical assistance programs Will you have other prescription drug coverage Yes M prescription drug in addition to this plan for which you are applying coverage You would not If yes please list your other coverage and your identification D number s for this coverage be able to enter Carrier information unless you f yes Carier Name Policy D for this coverage pled ea E U eee answer
77. fields that need to be corrected will show up in Red correct it and save again Source oub Source Referral General p Client Referral k Type sub Type Once errors are corrected click Review and Sign Review and Sign HE Agreement A Online Service Agreement Agreement with Humana This agreement is between you and Humana Inc on behalf of its affiliates Consent to Electronic Transactions Read the Service Agreement to the I the User and Humana acknowledge and agree to the following provisions cl ient and put a check mark In the 1 To conduct this enrollment and any changes made to this enrollment information through the use of Acknowledgment Box an electronic transaction which will be verified by the use of an electronic signature 2 This consent to conduct an electronic transaction only applies to enrollment services Click Agree 3 That may request that this Agreement be terminated If terminated paper access to enrollment services and forms will be distributed at no cost to me if an address phone number and a contact name are provided to a Humana representative 4 That may request a paper copy of this recorded transaction For More Information Humana 500 VV Main Street Louisville KY 40202 By checking this box you acknowledge you have read and understand the above information Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 20 10 01
78. following issues 1 Unable to Sync or Download 2 Unable to upload applications 3 Applications upload issue 4 Agent has certification and is unable to see the plans 5 MAPA fails to load an application Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 145 10 01 2012 How to Troubleshoot MAPA Go to Start gt All Programs gt Humana gt MAPA gt Troubleshoot A windows Messenger fm cA i T GuardianEdge fy Humana gy Uninstall MAPA Sprint fA CTA alaH beanice All Programs D Run A Log Off lo Shut Down ii start C atotusnotes CE MAPA versi When you Click on Troubleshoot MAPA will configure on Agent s machine Please wait Configuring Please wait Configuring MAPA 7 0 TTI T TTI TTI TTT Ty After Troubleshooting MAPA Log into MAPA Create a new Userld and Password for MAPA Log into MAPA again Connect to Humana and Synchronize then Download MAPA Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 146 10 01 2012
79. from your monthly Social Security benefit check The Social Security deduction may take two or more months to begin In most cases the first deduction from your Social Security benefit check will include all premiums from your enrollment effective date up to the point withholding begins Important note about Social Security Check Deduction Office Use Only Current Plan GR BN GR BN Plan Representative REP Affinity Partner Date Location Campaign Affinit Taxld Affinity Partner Location wg aed Referring Agent Agent Package Id eS Source Sub Source House Member ay Type Sub Type EE Disposition Disposition 2 Disposition 3 Main plan member enrolled Other Product Description OSB dental and vision understand that my signature or signature of the person authorized to act on behalf of the applicant under the laws of the State where he she resides on this application means that I have read understand and agree to the contents of this application Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 108 07 23 2012 Capturing Signatures Client After your client or someone acting as the Power Of Attorney POA for the client has read and understood the summary of the selected plan obtain a signature Click in the circle next to Client Sign to activate the signature pad Signature signature of applicant or authorized legal representative includi
80. ganization you should use this form This form may not be used to enroll in any Humana Medicare Advantage Plan for the first time Sections of thes form may have been prefilled for your convenience If any of thes profiled information es incorrect please make the necessary comections Note H plan is open your coverage will be effective the first day of the next month following the date Humana receives this completed form and any required anachments Please fill out the following Curent Lip Code Current County tam currently a member of the Humana Plan a HHumanaChoice PPO SNP OA RSG6 055 My current morthly premium is if appbcable New zip and county as same as current zip and county New Lip Code New county I would like to change to the Humana Plan 40288 JEFFERSON KY HumanaChoicePPO Renae Ole understand that this plan may have differant health and or prescnption drug benefits and hat a monthly pramiuen if applicable of Name of Plan you are Enrolling in Last Name First Name M I O Permanent Address 1 Permanent Address 2 aS Wily set SSS SY EE City State Zip County Phone Louii KY Cr JEFFERSON KY toe Release of Information By joining this Medicare health plan acknowledge that Medicare health plan will release my information to Medicare and other plans as is necessary for treatment payment and health care operations also acknowledge that Humana will
81. gnature pad Signature signature of applicant or authorized legal representative including valid Power of Attorn Capture Signature O Witness Sign signature Date Clear Signature Signature of VWitness Translator or person assisting in con BAGI Witness Translatar Last Name eee Felation Sl Note If the digital signature pad fails to capture the signature complete a paper application and contact CSS for a replacement Signature pad Put the signature tablet in a position where the client can comfortably sign on the tablet screen The tablet screen will light up and your client can sign on the tablet using the attached stylus Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 83 07 23 2012 Capturing Signatures Client As your client signs on the dotted line his her signature will appear in the Signature window on the laptop screen lf the client does not like the appearance of their signature they can try again after the signature on the tablet screen is cleared The signature can be cleared in one of two ways SEI Ee The client can tap on CLEAR on the tablet or e The agent can click on the Clear Client Signature button on the laptop When the client is satisfied with their signature the signature can be captured in one of two ways Capture Signature The agent can click on the Capture Client Signature bu
82. he individual s Medicare information for this section of the application as it appears on their card Demographics Medicare Card Other Coverage Medical Questions Payment Agent Only Medical Health Insurance Last Name Gender First Nare hull D O B E TT Please complete the information below as it appears on your Medicare card Medicare Claim Number Re enter Medicare Card Number Hospital Insurance Part A 1234567094 a 224557093 020171997 Phone Medical Insurance Part B 0101 1995 When completed click Next Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 59 07 23 2012 Medicare Supplement Application Other coverage This information pre fills from the RX calculator questioner You will only see this tab if you had to answer questions on the rate calculator lf your answer to Are you enrolling during Open Enrollment was YES you will not get this page Note It is necessary to review this information with the member Demographics Medicare Card Other Coverage Medical Questions Payment Agent Only GUARANTEED ACCEPTANCE DETERMINATION Please answer the following questions to determine if you are eligible for quaranteed acceptance to the best of your knowledge Are you applying for coverage during your Medicare Open Enrollment period If yes you quality for the Yes Mo Preferred rates Have you lost other
83. hone 502 444 5585 502 444 4444 Successfully Uploaded Applications Application Type Last Name First Name Phone Plan Name ApplicationiD wonka wally 502 444 4444 HumanaChoice PP Applications Which Failed To Upload Application Last First Type Description Neme Namea Plan Name BMTRUBBASXM21JC ndide Pot Flower CC gt ApplicationID Application Failed to Upload or Application Stuck on Machine or Application is Missing You should contact CSS At the time of the call you must be at your computer and have internet access CSS will take a snap shot of the application and send to IT to find out the issue They will need Member Name Member Medicare ID Application ID Date application was taken Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 135 10 01 2012 Application Status The application status report will allow you to keep track of all your submitted applications Connect to Humana Exit MAPA EES HUMANA Agent Self Service Center Click on wale On the POINT aaa Application Status Application Status 7 Welcome ourvey Weve come a long way team since we published the first On the Point publication on Waw 1 2001 Your accomplishments since then have MAPA Web HUMANA Agent Self Service Center Use the green down A tR rt arrows and enter the sos From Date and i DE l nae
84. how the member prefers the agent to contact them This will write to the Keywords box inCDS a2 MAPA Group Application Demographics Medicare Card Plan Specific Payment Agent Only Client Information Zip Code County BULLITT KY v Employer or Union Name COPPERWELD VEBA vi Available Plans Copperweld Veba GPFFS 078 065 v Medicare Eligible Retiree v Last Name E First Name o MI Fe o Address 1 Address 2 APT State Zip County Phone eRe RE EE Email Address Optional as Email Address If available will be used as a means to communicate various Hum Preferred Method of Communication Telephone Email Mail Person to notify in case of emergency nearest relative or friend Optional Last Narne First Name Ml Relationship To Applicant Phone Oo p ae Back Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 14 07 23 2012 Last Name First Mame Medicare Card Tab Group Application This section is requires the clients Medicare information Complete the individual s Medicare information as it appears on the Medicare card Some fields will not allow data entry unless their section requires information If the client does not have Medicaid you would leave the choice as No You would not be able to enter information into the Medicaid box unless you selected Yes as the
85. ic Transactions the User and Humana acknowledge and agree to the following provisions 1 To conduct this enrollment and any changes made to this enrollment information through the use of an electronic transaction which will be verified by the use of an electronic signature N h th li t 2 This consent to conduct an electronic transaction only applies to enrollment services ow you nave the online service agreemen 3 That may request that this Agreement be terminated If terminated paper access to read this to the member and have them enrollment services and forms will be distributed at no cost to me if an address phone number and a contact name are provided to a Humana representative Check the box and click Agree 4 That may request a paper copy of this recorded transaction 5 To be bound by this agreement as stated by law throughout the term of this Agreement 6 This agreement may be modified at any time if Humana provides notice For More Information Humana 500 V Main Street Louisville KY 40202 C By checking this box you acknowledge you have read and understand the above information Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 94 07 23 2012 Abbreviated Enrollment Form AEF Now review the application with the member before signing 4 Abbreviated Enrollment Form Summary if you are changing plans within the same Humana Medicare Advantage Or
86. icare Supplement Application Note not all states allow electronic submission If Available Plans show no plans available your state does not allow electronic submission Other states will be activated for it as DOls approve Humana s electronic enrollment process How to start Enter the zip code and the county of the member 4 Rate Calculator Humana Insurance Company of Kentucky 2432 Fortune Drive Lexington KY 40509 Zip Code 40299 County BULLITT KY v State KY Medical Insurance Part B 001 2011 The effective date is usually the first of the following month The effective date can be Effective Date 170172011 changed up to 3 months out except WV which only allows enrollment month prior to Date of Birth 0021343 effective date Gender O Male Female Available Plans Humana Medicare Supplement Plan B PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR KNOWLEDGE Are you applying for coverage during your Medicare Supplement Open Enrollment Period Yes Mo Have you lost or are you losing or replacing other health coverage which would gualify you for guaranteed O Yes ONo acceptance All applicants must answer these questions unless applying during a Medicare Supplement Open Enrollment Period or qualify for quaranteed acceptance Did you have Medicare coverage prior to age 657 Yes No Have you used tobacco products within the last 12 months Yes Mo If your application is a
87. iew and Sign form Client Information Zip Code Coury My Current monthly premium is if applicable Humana Medicare Advantage Effective Date 10 01 2009 OSB Riders Riders M MYOPTION ENHANCED DENTAL M MYOPTION VISION Make sure if they already have an OSB you have both selected on this form Grimlin P v a oo oO wn w Ww 3 D Residential Address 1 No PO box for the address 1212 Slim lane City State Phone 502 668 8888 Member ID Number As listed on your Humana Identification card Medicare Claim Number 123456769a Preferred Method of Communication Telephone Email Confidential and Proprietary to Humana Inc Humana Internal Use only BULLITT KY Name of Optional Supplemental Benefit you are enrolling in Enrollment in a Medicare Advantage Plan is required for Enrollment in a Humana Optional Supplemental Benefit am Currently a member of the Humana Plan HumanaChoicePPO H1806001 Optional Supplemental Proposed Effective Date Effective date is always the 1 of the following month f you are currently enrolled in an OSB you must select it on this form to continue receiving this benefit Name of Plan you are Enrolling in HumanaChoicePPO H1806 001 First Name Ml Address 2 Apt Zip County 40299 BULLITT KY Re enter Medicare Number 1234567689a Mail For Training Purposes Only Not CMS Approved 107 07 23 2012 Optional Supplementary Benefit Sum
88. ign 0305046921 remove the default and add the correct one Source Sub Source House Member Referral General v Client Referral v Head v Type Sub Type Client JA v Disposition Disposition 2 Disposition 3 Sold MAPD v SNP Dual Eligible Diabetes v Source Type and Disposition e The source field is a high level look at where the lead came from This will pre populate is added in CDS e Use the drop down arrow to make the correct selections e Disposition 2 and 3 build off of disposition one e Not all of the second dispositions have a third option to go with it If there is not one available it will say no disposition available e You must select disposition 1 and 2 in order to continue on ICEP IEP SEP AEP OEPI Proposed Effective Date 11 01 2010 The system pre fills the enrollment option with the selection made on the Plan Eligibility screen The proposed effective date will default to the first of the month following month Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 37 07 23 2012 Agent Only Tab Individual Application Source Information Tier 1 What was the original source of the lead how did the client learn about Humana e Medicare campaign seminar ad e TIPS campaign seminar ad e Veterans campaign seminar ad etc Tier 2 Where they heard about the plan DMS call
89. individuals who are not adequately informed of a loss of creditable coverage or never had creditable coverage ERR SEP for individuals whose enrollment or non enrollment in a Part D plan is erroneous due to an action inaction or error by a federal ernployee Note Only use other as a ESR SEP for individuals with ESRD whose entitlement determination was made retroactively last resort option for the SEP selection SEP for individuals who enroll in Part B during the Part B General Enrollment Period am either losing coverage had from an employer or union or leaving employer or union coverage receive extra help paying for Medicare prescription drug coverage am no longer eligible for extra help paying for my Medicare prescription drugs If you select a reason code that is not available for this time period the system will tell you the SEP is not available and to select about election period This SEP is not available at this time Please select another one or select a different election period ok Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 28 07 23 2012 Demographic Tab Individual Application Complete the client s Demographic information for this section of the application some fields will not allow data entry the data is tied to choices made during the process and can not be changed e Enter the Zip Code this will activate the County
90. ing Purposes Only Not CMS Approved Humana Internal Use only 87 07 23 2012 Saving the Application To ensure your application signature is Saved you must hit the Save and Close bution located at the bottom of the application If you click the X in the upper corner the signature will not save Click on the Save and Close button to save the application Save and Close ES Error Errors have been found Please correct before signing lf you make a mistake or forget something on the review and sign Check the following Signature information 1 Witness Last Name Required page you will see the error box 2 Witness First Name Required showing what corrections need 3 Witness Relation Required to be made Check the following Verifier Information 1 Provide Verification information or Reason for not verifying Application Updated A message box will indicate the Application 6MTRL85JDH42KRG Successfully Saved application has been saved Your application is now completed Once you click OK you will return to the MAPA Workbench Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 88 07 23 2012 Eligibility Determination AEF A Eligibility Determination Please select a plan type Select the plan type the member wants to enroll in MAPD MA PDP The plan you select here will determine plans that you receive on the application Are you
91. into the field Click on the OK button to close the message box Capture Signature sities Signature Date Clear Signature Witness Sign Witness Signature Captured signature of Witness Translator or person assisting in completion of form other than plan representative Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 48 07 23 2012 You will now be prompted to enter the Witness First Name Witness Last Name and Relation to Applicant in the fields under the witness signature Witness Translator Last Mame Witness Translator First Mame PO pO Relation pt lf someone is acting as the POA that person will sign in place of the member and their personal information will need to be entered in the fields at the bottom of the application You as the agent are not the authorized representative If you are the authorized legal representative you must sign above and provide the following information Last Name First Mare tll Address1 Address2 City tate Zip po gH L Phone Relation to Applicant GR BN 235350 O01 Verifier Verification Reason for not verifying When both signatures have been captured and the witness information has been entered in the appropriate fields you are ready to call for verification Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal
92. ions Dispositions Disposition not available Proposed Effective Date Products Discussed Please select ALL that apply Other Other Proguct Description JPOP For Training Purposes Only Not CMS Approved 07 23 2012 B MedSupp Confidential and Proprietary to Humana Inc Humana Internal Use only 125 Affinity Partners se the drop down arrow to select the correct Office Use Only Partner if no select None Plan Representative Location REP Affinity Partner Select A Partner v Date Health Plan One Health Plan Services Referring Agent Agent Afinity TID Healthy American Hershend Fam Entertainment Humana Guidance Center Attachments Hamon AMoO02 C AMOO6 Indiana Farm Bureau Affinity Partner lf the affinity partner is Wal mart Wallan the store number must be listed Affinity Partner Location Search Store If you don t know the Store ID e Click on the Search Store ID button e Leave ID blank and click Search e Enter State and City of the store Was this Sale originated from a WalMart Store Leave Store ID Blank Store ID _ Was this Sale originated from a WalMart Store State cy Ear If the affinity partner is a Humana Guidance Center the location must be entered Affinity Partner Health Compare Health Plan One 613 8648 Skillman Street Health Flan Services 61 2257 S 108th Street Healthy American 61 227 Willow Bend Hershend Fam Entertainment 1
93. lease my information to Medicare and other plans as is necessary for treatment payment and health care operations also acknowledge that Humana will release my information including prescription drug event data to Medicare who may release it for research and other purposes which follow all applicable Federal statutes and regulations The information on this enrollment form is correct to the best of my knowledge understand that if intentionally provide false information on this form will be disenrolled frorn the plan understand that my signature or the signature of the person authorized to act on behalf of the individual under the laws of the State where the individual resides on this application means that have read and understand the contents of this application If signed by an authorized individual as described above the signature certifies that 1 this person is authorized under State law to complete this enrollment and 2 documentation of this authority is available upon request by Hurnana or Medicare have Read and Understand the Statements Above Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 82 07 23 2012 Capturing Signatures Client After your client or someone acting as the Power Of Attorney POA for the client has read and understood the summary of the selected plan obtain a signature Click in the circle next to Client Sign to activate the si
94. m House Member use to determine head of house or spouse for CDS use Type and Sub Type use client and A Disposition use the drop down arrow and select the sold reason Enrollment reason mark the enrollment period which allows the member to enroll if SEP is selected you will need to also select the SEP reason Campaign refers to the Affinity partner key code this is located on your calendar activity if you down load this will pre fill if using blank app you will need to take out the default and add the correct code Products discussed Mark all products you talked about during your visit This should match your Scope of Appointment Proposed effective date defaults to the first of the following month you are in You can change the date to reflect no more then 3 moths out Tier 1 tells what the original source of the lead was Tier 2 Tells where the beneficiary heard about the plans Location where the application was signed Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 36 07 23 2012 Agent Only Tab Individual Application Plan Representative Date and Rep will pre fill Use the drop do Office Use Only i al L el l nc al I L e al tner 5 sele f l C i G Plan Representative Location P Affinity Partner e 17532 Select A Partner j Affinity TID Affinity Partner Location Agent Campa
95. mary Review and Sign form Monthly Premium Your Monthly Payment for your Humana Plan will be no more than 222 00 Your monthly payment for your Optional Supplemental Benefit s will be Review the rate for all the plans Your total monthly payment will be no more than Please select a premium payment option You can pay your monthly plan premium by mail using a Coupon Book Electronic Funds Transfer or Automatic Credit Card Charge You can also choose to pay your premium by automatic deduction from your Social Security Check each month Your Optional Supplemental Benefit Premium will be added to your Humana Medicare Advantage plan premium as one combined Premium therefore you may only select one Premium Payment Option If you choose a Premium Payment Option that is different from what was previously selected for your Humana Medicare Advantage plan this will replace the previously selected Premium Payment Option If no Premium Payment Option is selected below your previously selected Premium Payment Option will be Payment Options Social Security Benefit Check Deduction Coupon Book Credit Card N brates Payment option is the same for all plans Visa MasterCard Discover Card Number Credit Card Expiration Date a Auto Credit Card Charge Please provide the following information Bank Name Routing Number Account Electronic Funds Transfer EFT Please Provide the following Checking Savings Social Security Automatic deduction
96. messages continued To check system status when an error message is received Click on Information from the MAPA landing page File Information Reports Help MAPA Workbench Connect lo Humana Exit MAPA CI Disable State Selection Application Type i i Selected States FL GA KY Maintenance information will be listed User information reviews which password should be used to connect to Humana HE Information Language English Spanish Plan Type Humana CarePlus O AEF Group O Individual O OSB Member Authorization SOA OFSB O REAL For Me O Medicare Supplement Single Husband and Wite Information Maintenance Information Humana Sun Mon Tue Wed Thu Fi Sat j i 2 4 5 6 T amp 9 0 141 W 13 4615 16 17 i 20 21 22 23 H 25 26 N 28 29 30 J l i C Today 1032012 You may experience Log In problems due to SOLAR DOWNTIMES as follows INIGHTLY 2 AM EST 2 30 AM EST SUNDAYS 12 noon EST 5 PM EST and 2 AM EST 2 30 AM EST During these times MAPA may not be available for SYNCHRONIZATION DOWNLOAD OR UPLOAD you attempt to SYNCHRONIZE after receiving a message that you are not Licensed or certified Your plan data will be erased Please wait for a successful connection before attempting a sync User Information Agent Information MECA Agents MECA agents must use their AGENT PORTAL UserName and Password Career or Captive Career
97. mitting more than your first month s premium Initial Payment Visa hasterCard C Discover eg Automatic Withdrawal indicated below in amounts appropriate to my coverage and authorize the bank named below to debit credit same to such account authorize Humana to change the amount of the debit credit provided that arn given reasonable written notice at least 30 days in advance ofthe change This authorization is to remain effective until give Humana and the bank reasonable notice of termination MM Card Number Expiration Date l uture Fayment Uptions You can pay your premium monthly by automatic bank withdrawal credit card charge or coupon book Choosing automatic bank withdrawal or credit card charge provides a 2 discount on your monthly premium Generally automatic bank withdrawals and credit card charges are made the first week of each month hereby authorize Humana to initiate debit credit entries to my Checking Saving account and or credit card as C Visa indicated below in amounts appropriate to my coverage and authorize the bank named below to debit credit same to such account authorize Humana to change the amount of t reasonable written notice at least 30 days in advance of the change MasterCard Ea until give Humana and the bank reasonable notice of termination C Discover Checking Savings Depository Bank Name Automatic Withdrawal C Coupon Book P Routi
98. n Date Entered Mame of Institution Sa Address 1 Address 2 Aptt Note the language preference will write to the Smart Pad in CDS the part A and B dates Medicare effective date will write to the Benefits tab under policies Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 31 07 23 2012 Clinical Qualifying tab Individual Application This tab will only open if you selected a Special Needs Plan on the Demographic Tab 1 Qualifying questions you must answer yes or not sure to qualify for the plan 2 Medical questions You must enter any drugs that the member is taking for the special needs illness 3 Physicians you must enter either the primary care physician or the specialist it is ok to have both but not necessary Demographics Medicare Card Clinical Qualifying Plan Specific Payment Agent Only Pre qualification Assessment for Osteoarthrities Last Name First Name Mil Address 1 Address 2 APT City State Zip TE You musta Clinical Qualifying Questions 1 Have you ever been told by your physician that you have osteoarthritis or degenerative joint disease Yes ONo ONot Sure 2 Do you take any medications to help control the pain in your joints as m m a result of osteoarthritis or degenerative joint disease OYes ONo Not Sure Medical Questions 1 What medications for Ost
99. n Signature Captured message will appear TE and the client s 2 ae 101200 Signature Date will automatically be entered into the field Click on the OK button to go to ee E the next step ok Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 69 07 23 2012 Capturing Signatures Witness Usually a witness signature will not be necessary for the application Some situations where a witness signature would be captured are when e The applicant wishes for someone else family member friend to sign the application as a witness e The applicant cannot physically completely sign their name i e they sign an X on the tablet By clicking the Witness Translator Sign radio button the Capture Client Signature and Clear Client Signature buttons change to Capture Witness Signature and Clear Witness Signature respectively The signature tablet is ready for the witness signature If the witness does not like the appearance of their signature they can try again after the signature on the tablet screen is cleared The signature can be cleared in one of two ways e Tab clear on the signature pad e The agent can click the clear witness signature button Once the witness signature is captured a Witness Signature Captured message will appear and the witness Signature Date will automatically be entered into the field Click on the OK button to close th
100. n Services Referring Agent Agent Afinity TID Healthy American Hershend Farm Entertainment Humana Guidance Center Attachments OaAmoo1 OAM C AMOo06 Indiana Farm Gureau Insphere Kelse lf the affinity partner is Wal mart the store number must be listed If you don t know the Store ID Click on the Search Store ID button Leave ID blank and click Search e Enter State and City of the store WalMart Was this Sale originated from a WalMart Store State cy Ean If the affinity partner is a Humana Guidance Center the location must be entered Affinity Partner Health Compare Health Flan One Health Flan Services Healthy American Hershend Fam Entertainment Humana Guidance Center W Indiana Farm Bureau Insphere Affinity Partner Humana Guide Affinity Partner Location le Confidential and Proprietary to Humana Inc Humana Internal Use only 64 STOREID ADDR1 CTY 10613 g646 Skillman Street Dallas TH 10615 2257 S 100th Street West Allis WI 40616 227 Willow Bend Crystal MN 0617 11316 Montgomery Road Cincinnati OH 10618 T666 Nob Hill Road Tamarac FL 10619 12100 E Colonial Dr Orlando FL 0620 215 Englewood Road Suite A Kansas City MO 10621 3189 W Vine Street Kissimmee FL 10622 7945 Harlem Burbank IL 10623 5943 E McKellips Rd Ste 106 Mesa A 10624 975 W Charleston Blvd Las Vegas NV 10626 7915 N Hale Ave Peoria IL 10627 7400 Gall Blvd Zephyrhills FL 17673 1000 N Green Valley Parkway
101. n Specific Payment Agent Only Client nner ain Zip Code County Date Of Birth 40299 BULLITT KY g 0101 1936 1 Use the drop down arrow under Available plans Available Plans and select the Select a Plan plan Humana Gold Plus HMO SNP DB H1036 121C Humana Gold Plus HMO SNP DOB H1036 121 G Humana Gold Plus HMO SNP OA H1036 1220 Humana Gold Plus HMO H1036 053A Humana Gold Plus HMO SNP DE H1036 1034 HurnanaChoiceRPO SNP OA R5626 051 HurnanaChoicePPO RS626 018 HurmanaChorcePPO RS5626 005 Humana Gold Choice PFFS H1004 145 HMO SNP OA is for Osteoarthritis HMO SNP DB is for Diabetes Osteoarthritis 2 You must answer yes to this question or you are not eligible to enroll in the SNP plan Have you been diagnosed and are currently being treated for Osteoarthritis Demographics Medicare Card Clinical Qualifying Plan Specific Payment Agent Only Client Information Zip Code County Date Of Birth Available Plans Humana Gold Plus HMO SNP DB H1036 121C v Riders Last Name First Name Address 1 Address 2 APT City State Zip County Phone Bse BROWARDFL oa Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 30 07 23 2012 Medicare Card Tab Individual Application This section is requires the client s Medicare information Complete the individual s Medicare information as it appears on the
102. nal Use only 12 07 23 2012 Saving the Application A Test application box has been added to all applications ApplicationID Check marking this box will keep the application from fully uploading Application SC7TV7C3QFIK27HC Successfully Saved The Test application will appear in your application list until you complete an upload process at which time it will l Check here if this is a test application be removed OK Type Last Hame y First Hame City State Zip al Phone Stakes SHA erakar chiara 1515 willow rad lanteilla WY Gia Gl 266 46s Camplata FSE the lala wiliam 114 warkeck sheet Jouke KY 40259 SOF ITS Complete SA candy banal 1515 weet main loniwvilte KY iira MAbs Te 15145 deg lane louisville BY HY GAG GE Can F FSH pp na Fhmgg n Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved 73 07 23 2012 Humana Internal Use only Group Application Demographic Tab Complete the client s Demographic information for this section of the application some fields will not allow data entry the data is tied to choices made during the process and can not be changed Enter the Zip Code this will activate the County field Using the drop down select the County this will activate the Available Plans Using the drop down in Available Plans this will activate the category Enrollee Use the drop down to select the correct enrollee Preferred method of Communications This is
103. nding on your answer to a question will depend on the next question you need to ask Ex if you say yes to the medical assistance through the State Medicaid program You will need to answer the A and B if you say no A and B will grey out and you will go to the next question OTHER COVERAGE INFORMATION Are you covered for medical assistance through the State Medicaid program C Yes C No NOTE TO APPLICANT If you are participating in a Spend Down Program and have not met your Share of Cost please answer NO to this question al If yes will Medicaid pay your premiums for this Medicare Supplement policy C Yes Mo bi Do you receive any benefits from Medicaid OTHER THAN payments toward Your Medicare Part B premium C Yes No lf you had coverage from any Medicare plan other than original Medicare within the past 63 days forexample a Yes No Medicare Advantage plan or a Medicare HMO or PPO fill in your start and end dates below If you are still covered under this plan leave END blank START END open this field al If you are still covered under the Medicare plan do you intend to replace your current coverage with this new Medicare Supplement policy bi Was this your first time in this type of Medicare plan c Did you drop a Medicare Supplement policy to enroll in the Medicare plan Do you have another Medicare Supplement policy in force al lf so with what company and what plan do you have bi If so
104. ng Number Account Number beres 23 Clear Payment Anytown USA PAY TO THE ORDER OF _ FOR H 23S6789 O00234 56789 100 ABA Check Routing Number Account Number Check Number 223456789 000323456789 2001 lt Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 62 07 23 2012 Medicare Supplement Application Agent Only Affinity Partner use the drop down arrow to select Affinity partner Location only used if partner is Wal Mart would be store number Referring Agent only used if this was a broker referral must be added before app is signed Source and Sub Source for CDS refers to where the lead came from House Member use to determine head of house or spouse for CDS use Type and Sub Type use client and A Campaign refers to the Affinity partner key code this is located on your calendar activity if you down load this will pre fill if using blank app you will need to take out the default and add the correct code Company enter the name of an policies that will remain active once this plan becomes effective If there is not one enter None Type enter the type of plan that will remain in effect once this plan becomes effective Disposition the 3 tiered disposition resembles the new CDS version In disposition 1 select the correct sold product Then select reasons for enrolling under disposition 2 and 3 Produc
105. ng valid Power of Attorn Capture Signature O Witness Sign signature Date Clear Signature Signature of VWitness Translator or person assisting in con BAGI Witness Translatar Last Name eee Felation Sl Note If the digital signature pad fails to capture the signature complete a paper application and contact CSS for a replacement Signature pad Put the signature tablet in a position where the client can comfortably sign on the tablet screen The tablet screen will light up and your client can sign on the tablet using the attached stylus Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 109 07 23 2012 Capturing Signatures Client As your client signs on the dotted line his her signature will appear in the Signature window on the laptop screen lf the client does not like the appearance of their signature they can try again after the signature on the tablet screen is cleared The signature can be cleared in one of two ways SEI Ee The client can tap on CLEAR on the tablet or e The agent can click on the Clear Client Signature button on the laptop When the client is satisfied with their signature the signature can be captured in one of two ways Capture Signature The agent can click on the Capture Client Signature button on the laptop screen The client can tap on OK on the tablet or Signature
106. nty Date of Birth social Security Number 40299 BULLITT KY 06 15 1919 111 11 1111 Available Flans Re enter SSN Prepaid Dental C550 114 171 1111 Last Name First Marne Middle Initial MONSTER HENRY OO Permanent Address 1 Permanent Address 2 Apt City state fin County PELLA 40299 BULLITT KY Daytime Phone Optional Home Phone Required Sener 333 333 3333 641 620 3631 Male Female Language Preferences Other Language a Optional Humana Medicare Re enter Humana Medicare Date of Birth Member IIHI Member IOWHIC M Last Mame First Mame Middle Initial C Same as Member Address Permanent Address 1 Mot a PO Box Permanent Address 4 4 pt tf Gender City State Zip Phone Female Social Security Murnber Re enter Soh Dental Facility Murmber Your Monthly Premium 25 08 Monthly premium includes 1 Administrative fee One time Enrollment Fee non refundable Total Initial Payment single Payment Option 323 96 Saves 11 Yr m fw e Tol ao m a Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 130 07 23 2012 Free Standing Benefits FSB Review and Sign The FSB application could require up to 5 signatures The Client and Agent will always sign e Spouse will have to sign if being insured Payor will sign only if someone other then the primary insured is paying the premium e Witness Translator will sign if the application needed to be tr
107. o cost to me if an address phone number and a contact name are provided to a Humana representative 4 That may request a paper copy of this recorded transaction 5 To be bound by this agreement as stated by law throughout the term of this Agreement 6 This agreement may be modified at any time if Humana provides notice For More Information Humana 500 VY Main Street Louisville KY 40202 w By checking this box you acknowledge you have read and understand the above Information Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 116 07 23 2012 Member Authorization Form Review and Sign 4 Member Authorization Form Summary Client Information ip County Date of Birth 40299 BULLITT KY 10 5 1943 Last Name First Name ML Review the demographic Information Permanent Address 1 Permanent Address 2 City tate Lp County Phone 401298 BULUT KY 6029996678 HA HHEN Optional Email Address By providing your emailiohone number you consentto receiving information via email or phoned Gender Medicare Claim Number Re Enter Medicare Claim Number lale Female Product Selection Yes ld like to recewe information on the following non health related products and services please check all that apply Life Insurance Products Other Insurance Products including hospital accident long term care and disability Annuities Make sure at least one all ofthe above
108. ofthe above Humana can only contact the client Yes I d lik f bout these fi d ff hen th lable pl heck apelbepics es I d like to receive information about these future product offerings when they are available please chec P 9 p selected on the all that apply form W Health insurance spending account Travel Insurance Products Pet Insurance _ All ofthe above Office Use Only Plan Representative Agent The agent information Agent Dummy ooo d HH will pre fill Date Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 115 07 23 2012 Member Authorization Form Review and Sign The client will be asked to acknowledge that they are in agreement to the electronic signature and submission ES Agreement aH A Online Service Agreement Agreement with Humana This agreement is between you and Humana Inc on behalf of its affiliates Consent to Electronic Transactions the User and Humana acknowledge and agree to the following provisions 1 To conduct this enrollment and any changes made to this enrollment information through the use of an electronic transaction which will be verted by the use of an electronic signature 2 This consent to conduct an electronic transaction only applies to enrollment services 3 That may request that this Agreement be terminated If terminated paper access to enrollment services and farms will be distributed at n
109. ollment services and forms will be distributed at no cost to me if an address phone number and a contact name are provided ta a Humana representative 4 That may request a paper copy of this recorded transaction For More Information Humana 500 VV Main Street Louisville RY 40202 By checking this box you acknowledge you have read and understand the above information Ask the member if they Agree or Disagree to the service agreement Click the appropriate box Note if the member disagrees you will need to start over with a paper application Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 67 07 23 2012 Capturing Signatures Client After your client or someone acting as the Power Of Attorney POA for the client has read and understood the summary of the selected plan obtain a signature Click in the circle next to Client Sign to activate the signature pad You have completed and reviewed the following applications and or forms Reviewed and acknowledged Notice of Replacement Form Not Applicable Total Monthly Medicare Supplement Premium 231 See Prin ela Signature NES of applicant or authorized legal representative fincluding valid Power of Attorney Legal Guardian etc Client Sign signature Date Capture Signature O Witness Sign signature Date Clear Signature i i signature of Witness Translator or person assisting in con
110. ollows e If application is received between the 1st and 15th of the month the policy effective date will be the 1st of the next month e If application is received between the 16th and end of the month the policy effective date will be the 1st of the 2nd following month Example App received May 18th for processing policy effective date will be July 1st The reason for the difference in effective dates is due to the member having to select a primary care dentist and being included in the monthly membership rosters sent to providers Dental Preventive Plus PPO and VCP or Focus Vision plan effective dates are calculated as follows e Applications received between the 1st and end of any month will have a policy effective date of the 1st of the following month e If application is received between the ist and 15th of the month the policy effective date can be the 1st of the current month if it is requested and indicated on the application Note if paying monthly a double deduction will be taken for the first payment Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 128 07 23 2012 Free Standing Benefits FSB Review and Sign Referring Agent If lead came from broker referral the agent needs to be added Do you want to enter Referring Agent H Error Page e The system will scan Following field s in Payment page has error s the application
111. or Captive agents should use their HSS UserName and Password Delegated Agents Delegated agents must use their AGENT PORTAL UserName and Enrollers must use their HSS UserName and Password Confidential and Proprietary to Humana Inc Humana Internal Use only For Training Purposes Only Not CMS Approved 10 10 01 2012 synchronize When to Synchronize First time users need to update plan data and zip code tables before creating their first application e Any time operations sends an email advising of plan changes e Every Monday morning e To activate synchronize you need to first Connect to Humana It is very important to Synchronize before Downloading A MAPA Workbench Humana Welcome Rebecca Boston Please remember to Synchronize and DOWNLOAD a emea Exit MAPA Download Click on synchronize MAPA Home Disable State Selection Selected States Ky synichromzng Data Please Wait Database Synchronized successfully TTT OK Downloading GetAllMarkets Data You need to Synchronize plan data once a week Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 11 10 01 2012 Synchronize syncOnce Automatic MAPA version update New MAPA versions will be pushed during the Synchronization step e Connect to Humana e Click synchronize e Click YES do you want to upgrade Meca agents Agent portal User
112. ou are tha authorized Legal Representative POA you must provide the following information Last Mame First Name til Po ee ee Address Address2 mE _ gt Gomplete this information for the City State Zip Power of Attorney Phone Relation to Applicant po ae Click Save and Close Return To Application When every thing is Save and Close completed Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 22 07 23 2012 Scope of Appointment reload to create application Once you have completed the presentation and the beneficiary has decided to purchase the plan the agent needs to reload the SOA and create that application from there This will make sure the SOA is tied to the application Reload the SOA From the MAPA workbench page click on the application you need to reload Once highlighted click Load APP Application Search SearchBy AI Complete Incomplete Clone App Load App Delete App Last Name First Name Address Status f melly Street Louisville p 6 Complete To be Completed by person with Medicare The SOA will open on the main page Please check the box beside the plan type you want the agent to discuss with you If you do not want the agent to discuss a plan type with you please leave Client Information Zip Code County 40299 JEFFERSON KY v O Stand alone Medicare Prescription Drug Plans Part
113. ou can also choose to pay your premium by automatic deduction from your Social Security Check each month Your Optional Supplemental Benefit Premium will be added to your Humana Medicare Advantage plan premium as one combined Premium therefore you may only select one Premium Payrnent Option lf you choose a Premium Payment Option that is diferent from what was previously selected for your Humana Medicare Advantage plan this will replace the previously selected Premium Payment Option If no Premium Payment Option is selected below your previously selected Premium Payment Option will be applied If no Payment Options O Social Security Benefit Check Deduction 2 Railroad Retirement Board Benefit Check Deduction You must currently be receiving a Railroad Retirement Board benefit check in order to qualify for this payment option O Coupon Book Credit Card Mame Co Visa Clin Titel ard gt Discover ag Credit Card Mumber Credit Card Expiration Date Electronic Funds Transfer Depository Bank Mame Routing Mumber Account For es SS ee i ee eS tf beau SLFS i Les SbLFATLOL s bank account ber ABE OF nk routin number e MATI Electronic Funds Transfer EFT Please Provide the following Checking Savings Office Use Only Current Plan GREN GR 233350 BN Plan Representative REP Affinity Partner z Location Campaign Affinit Taxld Affinity Partner Location Sd _z Referring Agent Agent
114. p determine the election period options you receive elect a plan yeal 2011 From Jan 1 thru Oct 15 the plan 2012 The plan year only needs to be selected from Oct year will be greyed out 15t thru the end of Nov Determine Eligibility Click here to get election period options Select an Election Period if not enrolling using a SEP ICEP IEP SEP AEP OEPI Proposed Effective Date Once you have the information completed click Determine Eligibility andthe system will activate the election codes that are available Select the correct election period and click continue eomme Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 21 07 23 2012 Eligibility Determination Individual Application lt Eligibility Determination Please select a plan type MAPD O MA O PDP Selecting YES requires the county Zip code and Sep reason code Are you enrolling using a SEP Mote Click Yes ta select SEP reason Wes gt No ip Code SEP Reason Code Date of SEP event SEP Other Some SEP reason will This is only used if you select other as require a date he SEP EE Select SEP Reason Code ReasonCode Description a j k CHR One time SEP for Initial Enrollment into a Chronic Care SNP plan If SEP is the election i period you must select COS SEP for individuals enrolled in cost plans that are nonrenewing their contracts The reason for the SEP CRE SEP for
115. pe and Sub Type use client and A Disposition the 3 tiered disposition resembles the new CDS version In disposition 1 select the correct sold product Then select reasons for enrolling under disposition 2 and 3 Enrollment reason defaults to SEP reason Group Campaign refers to the Affinity partner key code this is located on your calendar activity if you down load this will pre fill if using blank app you will need to take out the default and add the correct code Proposed effective date defaults to the first of the following month you are in You can change the date to reflect no more then 3 moths out Presenter who was at the appointment with you Demographics Medicare Card Plan Specific Payment Agent Only Office Use Only Plan Representative Location REP Affinity TID 07 28 2009 Ee Referring Agent Agent Campaign Oooo o a Attachments LI AMOO AMOO2 C AMO BN on Presenter No Presenter Humana Presente Non Humana Preserrer Source oub Source Type oub Type Disposition Disposition 2 Disposition 3 Select A Disposition Disposition not available i Disposition not available ae ITEP IEF SEP AEP QEFI Proposed Effective Date SEP REASON CODE GRP Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 78 07 23 2012 Affinity Partners Affinity Partner VWWalhart Affinit
116. pen Enrollment was YES you will not get this page Note It is necessary to review the medical questions with the member A i r S Demographics Medicare Card Other Coverage Medical Questions Payment Agent Only YES OR NO ANSWERS WILL BE REQUIRED TO THE FOLLOWING QUESTIONS TO THE BEST OF YOUR KNOWLEDGE unless you indicated that you are applying for coverage during your Medicare Open Enrollment period or qualify for quaranteed acceptance In the last year have you been hospitalized confined to a nursing facility or are you bedridden or Vas Na confined to a wheelchair In the past 30 days have you received Home Health care Yes No Do you now have or within the last two years have you had or been advised by a physician that you need treatment or surgery for Heart Coronary or Carotid Artery Disease not including high blood pressure Peripheral Vascular Vas Mo Disease Congestive Heart Failure or any other type of Heart Failure Enlarged Heart Stroke Transient Ischemic Attacks TIA or Heart Rhythm Disorders Emphysema Chronic Obstructive Pulmonary Disease COPD or other Chronic Pulmonary disorders Yas No Have you used supplementary oxygen in the last year Parkinsons Disease Multiple or Lateral Sclerosis Huntington s Disease Muscular Dystrophy Lupus Vas Mo Hepatitis or Lou Gehrig Disease Alzheimer s Disease senile dementia organic brain disorders senility disorder schizophrenia other Va
117. pload justification ween For Not li pine cing Applications must be uploaded oeae Wallon ou tie abeadag Ua ure Eel Uplanuied Oia Ui bolas of tecepisten every night p Select the he d be ei x jete CSS T che Number S qnature Date 7 19 2911 9 53 2 PM elect a Measor A 24 hour upload justification Computer issue enter ticket number here onmmection issue section has been added Forgot ret vert voled Signa raato KILAS 41 Thane The Hy G f e FEES MOOT 9 PN inationn GOOKRILASESAXHA Palmer Humana Walmart Prefenec 722011 11 19 PM lf an application IS not GOOKFIZAGLI4YVD Dees HumanaCracePFO RTQ 7 1 W201 1120 Ph uploaded 24 hours from the time signed justification must be provided ee Cancel Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved 134 10 01 2012 Humana Internal Use only Uploading Upload Completed Applications Below is an example of a upload summary UPLOAD STATUS REPORT Upload Complete Uploaded Applications Added Contacts Updated Contacts Disposition For Contacts Non TM Lead Disposition For Contacts TM Leads CDS Contacts Updated ApplicationiD Last Name First Name KS BMTRLEB45XM271JC Pot Flower aoe SEMTRLSS2N182LP6 Wonka Willie yed C7TV7CS0XB0S3 YX wonka lt g CDS Contacts Which Failed to Upda ApplicationiD Descriphoa x Last Name First Name Phone C7TV7C30XB0G3 YX ah wonka wally 902 444 4444 poe 25 P
118. pplicant Return To Application ES SOA Application Types Please select a Application Type The Application Types box will Code Description SelectApplication appear select the correct application IND Individual Application then click OK AEF Abbreviated Enrollment For The application will open to the Eligibility Determination Page Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 24 10 01 2012 Scope of Appointment reload to create application Complete the Application A Eligibility Determination Please select a plan type MAPD O MA O PDP Are you enrolling using a SEP Yes O No Note Click Yes to select SEP reason If you received a DMS lead that HAS an SOA with it please enter DMS Scope in that box Signature Seminar Enrollment Signature Seminar Enrollment SOA ID PSeminar Enrollment a A Seminar Enrollment Signature of Applicant or Authorized Legal Representative signature of Applicant or Authoriz O Client Sign signature Date ais signature of vitness Translator or Person assisting in Completion of form other than agent A Test application box has been ApplicationID added to all applications Application SC7TV7C3QFIK27HC Successfully Saved Check marking this box will keep the application from fully uploading Check here if this is a test application The Test application will appear in
119. r Services 1 888 839 7316 6M T RL85JDH42KRG Monday Friday 8 a m 6 p m TDD for hearing impaired 1 800 833 3301 Member Name _BU S Bunny Hour Precertfication 1 800 523 0023 Proposed Effective Date 0401 2009 Doctor and Hospital Preadmission certification is required for Plan Name Humana PPO Enhanced all nonemergency and nonurgent services for HMO plans however it is requested for PPO and PFFS plans Providers can call Provider Relations at 1 866 291 9714 for PCP Phone ift applicable pee plan terms and conditions Copayment PCP Specialist ER Medicare Plan GR __ 249673 _ Rx Plan PCN 03200000 BN OT BN 610649 03 02 09 Application ID Number Primary Care Physician PCP Rebecca Boston 03 02 09 Bugs Bunny Agent Signature Date Member Signature Date GN85023DRR 0206 Medicare approved HMO PPO PDP and PFFS plans Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 143 10 01 2012 Member Receipt For OSB All the information you need to complete the receipt is on the application this receipt is used when you write an OSB application Note At this time we do not have specialized receipts for the OSB applications below is an example of how to modify the MA receipts for the OSB NEVER add PHI e g SSN DOB information to a receipt Temporary Proof of Membership Humana Medicare Plans in Humana s Medicare Plans New Member Services 1 888 839 7316 6
120. r in both the MA plan plus OSB at the same time and this member is changing from one contract to another the Individual form is used If the agent is enrolling the member in a new MA plan under the same contract number with or without OSB the AEF is used lf the agent is enrolling the member in a MA plan only and it s the member s first enrollment or changing from contract to contract individual form is used lf the member already has an OSB plan and wants to purchase another the stand alone form should be used Agent must mark both OSB products old and new to ensure the member is not termed out of the original one lf the member wants to DROP an OSB and remain on the same base plan the member must call Customer Service No agent is allowed to do this via an application and may not be paid for it The Stand Alone OSB form displays available OSB s for current plan and calculates effective date based on current plan Note Renewing members adding OSB s during AEP will only get 1 1 effective date and AEP as the only option for Election Period Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 99 07 23 2012 Optional Supplemental Benefit Enrollment Form Application Type Language English Spanish Plan Type Select plan type and Humana Care Plus then application type AEF Group Individual gt is OSB Member Authorization SOA FSB
121. r one or select a different election period ok Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 90 07 23 2012 Abbreviated Enrollment Form AEF A MAPA Abbreviated Enrollment Form HUMANA midani w when you need it mosi A nana Medicare Advantage If you are changing plans within the same Humana Medicare Advantage Organization you should use this form This form may not be used to enroll in any Humana Medicare Advantage Plan for the first time Note If plan is open your coverage will be effective the first day of the next month following the date Humana receives this completed form and any required attachments Please fill out the following Currant Zip Code Current County am currently a member of the Humana Plan 40299 BULLITT KY v HumanaChoiceP PO R5626 066 v My current monthly premium is if applicable Old Rate C New zip and county as same as current zip and county New Zip Code New county would like to change to the Humana Plan BROWARD FL 7 HurnanaChoicePPO R5626 01 3 Riris Name of Plan you are Enrolling in OMYOPTION ENHANCED DENTAL HumanaChoicePPO R5626 005 O MY OR TON YSN a ee J La thau aAlranaAy AALA ARA VIA a rider puta t Remen ey already have one yc Last Name First Name M I Permanent Address 1 Permanent Address 7 State County Phone roward FL 33316 BROWARD FL 555 5
122. rders injuries Organ transplantation You are Eligible Please click ENROLL to continue Rate Preffered 199 00 Enroll Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 57 07 23 2012 Medicare Supplement Application Demographics Demographics Medicare Card Other Coverage Medical Questions Payment Agent Only Client Information A 1001 2007 Last Name Ge Nate must appear as itis on Medicare Card First Name Social Security Number Re enter SSH 01 11 1010 Optional 101 411 1010 Permanent Address Address 1515 Leafy Lane Address City Cd State fin County Malling Address If diferent from Permanent Address Address Addressz City state Lip E Email Address Optional Never use your email address E mail address if available will be used as a means to communicate only Humana Information Person to notify in case of emergency nearest relative or friend Last Name Relationship to Applicant First Name Phone PF ES KS lt When demographic info is completed click NEXT Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 58 07 23 2012 Medicare Supplement Application Medicare Card This section is requesting the clients Medicare information Complete t
123. re an Agent Support Specialist will be happy bo assist you Create a user id and password that will be Medicare Advantage Paperless Application easy to remember Create User Name robida Each time a new version of MAPA is installed Create Password DARACOTA you will need to change the password Confirm Password Coe OK Close Medicare Advantage Paperless Application Everyday login i aiii Oooo Enter the User ID and the Password that forgot my Login or Password you created and click OK Change my User Name or Password ok NOTE To change your password Put a check mark in the Change my Password box Click OK Enter your new password and then confirm the new password Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 4 10 01 2012 MAPA Workbench When you enter the MAPA program the Medicare Advantage Paperless Application main screen is displayed allowing you to e Connect to Humana to get behind the firewall so you can synchronize download and upload e Select the type of application e Search for contacts that you have down loaded and applications e Select the language for your application e Delete an incomplete application e Clone or copy an application e Create an application for a contact by using enroll e Create a blank application for a new contact e Scroll over calendar date to see what appointments you have scheduled e
124. ry of Enrollee HumanaChoicePPO R5826 008 Medicare Eligible Retiree ka Last Name Selected the correct plan First Name Ml Flubber Address 1 NO PO Box in the address Address 2 APT City State Zip County Phone 40299 BULLITT KY 656 555 5555 HE SH Mailing Address if different from Street Address Address 1 Address 2 APT City State Zip Email Address If available will be used as a means to communicate various Humana related information Optional Email Address Optional Preferred Method of Communication Telephone Email Mail Person to notify in case of emergency nearest relative or friend Optional Last Name First Name Ml MCMier Relationship To Applicant Phone 02 BEEBE iy a Application Review continued on next page Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 81 07 23 2012 Application Review Group Application The system has already scanned the application to ensure it was complete Medicare Health Insurance Last Name First Name NT ria E A Medicare Claim Number Re Enter Medicare Claim Check Medicare number Please complete the information to the right 1734567004 1234567904 exactly as it appears on your Medicare card Effective Date Please contact Humana at 1 000 033 2367 TOD SEK Hospital Insurance Part A 1 077 033 4406 if you need information in another format or language than what is listed Male oes below Our office hours
125. s No major depressive disorders mental or nervous disorders cirrhosis alcoholism or drug abuse Acquired Immune Deficiency Syndrome AIDS or AIDS Related Complex ARC or tested positive for Vas No exposure to the Human Immunodeficiency virus HW infection Kidney disease requiring dialysis or diabetes requiring more than 50 units of insulin daily Yas No Internal cancer leukemia or melanoma Vas Ne Amputation caused by disease or trauma or neuralgic or poor circulation that has caused an ulcer on the Vas Na skin Do you have any paralytic conditions Rheumatoid arthritis Paget s Disease degenerative bone disease crippling arthritis vertebral or hip Vas Mo fractures dislocatians spinal cord disorders injuries Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 61 07 23 2012 Medicare Supplement Application Payment Your payment amount will pre fill from the Rx Calculator this rate can not be changed here Select how you would like to make the initial payment complete any boxes that come up with that selection select how you want to make the future payments this may be different than the initial Demographics Medicare Card Other Coverage Medical Questions Payment Agent Only gt In order for us to process your application you must submit your first month s premium Initial Payment Enter Initial Payment only if you are sub
126. s insured click the box and information will pre fill Alternate Payor primary insured not paying for the plan add demographic information Ilf you are paying for the plan please provide the following information Then tell us how you would like to pay for the plan by completing the Payment Options If you will be paying for someone else s plan please also complete the Alternate Payor section below Last Name First Name Middle Initial Address 1 Permanent Address 2 Apt City otate Zip Daytime Phone Optional Home Phone Required If you are paying for an insurance plan for someone else please provide the following information about the primary insured whose plan you will be paying for Please note if you are paying for someone else s plan you will be responsible for signing this authorization to withdraw funds from your selected accounts not the primary insured Last Name First Mame Middle Initial MONSTER HENRY Ea Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 122 07 23 2012 Free Standing Benefits FSB Payment Important things to remember The standard enrollment fee can be waived when e The enrollment fee is only waived on Dental and Vision benefits e The enrollees must live in the same state e The payor must be the same on both applications lf you are the premary insured and paying for the plan then please check box
127. s something wrong on the application click Return to Application this will take you back to the tabbed section to make Changes No problems with the application click Next gt Review Client Information Proposed Effective Date 1001 2007 Last Name Mil E First Name Social Security Number Re enter SSM Autumn 101 411 1010 Optional 101 11 1010 Permanent Address Address 1515 Leafy Lane Address City ee Ctate fip County Mailing Address If different from Permanent Address Address OOXNL gt q so 5 5 5 gt Address City SaaS Se understand that if my application is not submitted during an Open Enrollment or guaranteed issue period Humana has the right to reject my application and any premiums paid will be refunded also understand that this policy will not pay benefits for stays beginning or medical expenses incurred during the first three months of coverage if they are due to conditions for which medical advice was given or treatment recommended by or received from a physician within six months prior to the insurance effective date Coverage is not limited if you enroll during an Open Enrollment or guaranteed issue period or satisfy the credible coverage requirements Any person who with intent to defraud or knowing that he or she is facilitating a fraud against an insurer submits an application or files a false or deceptive statement may be subject to prosec
128. sted while you are covered under the employer or union based group health plan If you suspend your Medicare Supplement policy under these circumstances and later lose your employer or union based group health plan your suspended Medicare Supplement policy or if that is no longer available a substantially equivalent policy will be reinstituted if required within 90 days of losing your employer or union based group health plan lf the Medicare Supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended the reinstituted policy will not have outpatient prescription drug coverage but will otherwise be substantially equivalent to your coverage before the date of the suspension Counseling services may be available in your state to provide advice concerning your purchase of Medicare Supplement insurance and concerning medical assistance through the state Medicaid program including benefits as Qualified Medicare Beneficiary QMB and a Specified Low income Medicare Beneficiary SLMB Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 60 07 23 2012 Medicare Supplement Application Medical Questions This information pre fills from the rate calculator questioner You will only see this tab if you had to answer questions on the rate calculator lf your answer to Are you enrolling during O
129. sting information for the particular plan the client has selected With the numerous plans the specific options for each will look different on the screen Demographics Medicare Card Plan Specific Payment Agent Only For example the PDP form to the right asks if the client has prescription drug coverage You would not f yes alee list your olhei er coverage si your identification number s for this coverage be able to enter Carrier information unless you selected Yes as the answer to the question fyes Camer Name Policy Some individuals may have other drug coverage including private insurance TRICARE federal employee health benefits Oes M coverage VA bel or state area assistance programs Will you have other prescription drug coverage DF for this coverage A E Medicare Card Clinical Qualifying Plan Specific Payment Agent Only Once enrolled will you or your spouse if married have other group health coverage Oves ONo If yes complete the following Carrier Name Carrier Address 1 Carrier Address 2 City state Zip Code Policy Once enrolled will you or your spouse If married work Oves Oro Do you have end stage renal disease OYes f Oto A If you do not need regular dialysis any more or have had a successful kidney transplant please attach a note or records from your doctor showing you do not need dialysis or have had a successful kidney transplant
130. t No ip Code 40299 SEP Reason Codes SEP Reason Code Date of SEP ewent SEP Other Some SEP reason will This is only used if you select other as require a date he SEP Select SEP Reason Code ReasonCode Description CHR One time SEP for Initial Enrollment into a Chronic Care SNP plan lf SEP is the election period you must select COS SEP for individuals enrolled in cost plans that are nonrenewing their contracts The reason for the SEP SEP for individuals who are not adequately informed of a loss of creditable coverage or ne never had creditable coverage ERR SEP for individuals whose enrollment or non enrollment in a Part D plan is erroneous due to an action inaction or error by a federal ernployee Note Only use other as a ESR SEP for individuals with ESRD whose entitlement determination was made retroactively last resort option for the SEP selection SEP for individuals who enroll in Part B during the Part B General Enrollment Period am either losing coverage had from an employer or union or leaving employer or union coverage receive extra help paying for Medicare prescription drug coverage am no longer eligible for extra help paying for my Medicare prescription drugs If you select a reason code that is not available for this time period the system will tell you the SEP is not available and to select about election period This SEP is not available at this time Please select anothe
131. t services 3 That may request that this Agreement be terminated If terminated paper access to enrollment services and forms will be distributed at no cost to me if an address phone number and a contact name are provided to a Humana representative 4 That may request a paper copy of this recorded transaction 5 To be bound by this agreement as stated by law throughout the term of this Agreement 6 This agreement may be modified at any time if Humana provides notice Have the member put a check in the box anc For More Information Then click AGREE Humana 500 W Main Street Louisville K E y checking this box you acknowledge you have reag and understand the above information as Once the agreement is completed you will be taken to the Review and Sign page Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 80 07 23 2012 Application Review Group Application When the program recognizes that the pad is connected to the laptop the program will then display a Summary page listing all the information that has been entered on the application Scroll through the application and review the accuracy of the information with the client You are reviewing the application for spelling errors and incorrect information Group Application Review and Sign Client Information Zip Code County Date Ot Birth Oia 40299 BULLITT KY Available Plans Catego
132. tary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 14 10 01 2012 Creating an Application ae Application T To create an application ee Language Select Language LS English Spanish Plan Type Plan Type Application Type L Humana CarePlus i AEF O Group Individual 2 OSB O Member Authorization SOA O FSB REAL For Me then Medicare Supplement Single Husband and Wife Click on Create Blank Application MAPA Workbench Humana Welcome Rebecca Boston Please remember to Synchronize and DOWNLOAD Application Type Plan Type Sun Mon Tue Wed Thu Fri Sat Tt 2 4 5 6 _ Humana CarePlus i 7 8 9 OW 1 12 13 Upload O AEF Group O Individual 415 16 17 18 19 20 OSB O Member Authorization 21 22 23 24 25 26 27 MAFA Home 28 29 30 Ji O SOA O FSB REAL For Me j m i i A ij 10 C Disable State Selection Medicare Supplement C Today 1032042 Selected States KY O Single Husband and Wife Contact Search Search By Al Find Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 15 07 23 2012 Scope of Appointment In conducting marketing activities and MA or part D plan sponsor may not market any health care product during a marketing appointment beyond the Scope of Appointment agreed upon by the beneficiary and documented by the plan prior to the appointment Distin
133. ted in the plan lf a paper scope of appointment is completed while in the field it must be returned to the market immediately so it can be scanned SOAs are kept on filed for 10 yrs For Training Purposes Only Not CMS Approved Confidential and Proprietary to Humana Inc 10 01 2012 Humana Internal Use only 16 Scope of Appointment To create an SOA for a new beneficiary click the Create Blank SOA C bisable State Selection Selected Stator HY Cantact Search PE Search the All App Thive i aai Home Firat Naine Adii esa Application Type Language L English O Spanish J Pian Type Sin ee Tia Wed Mi Fil S Lf Humane O Corel los e h n Ex sA AEF Group Individual i 15 6 1 18 61s 20 C 0568 Member Authorization oi 2 2 as A N ho soa O FSB O REAL For Me a ae O Medicare Supplement Today 1022042 Single Husbhand and Wile City Jip Slate e The scope of appointment can not be fully completed until the appointment is completed e The scope of appointment will remain on the MAPA Main page until the agent logs back in and updates the form with the status of the appointment If the application iscompleted from the SOA the information will update automatically e Once the information is added the application will send with the next upload Apylication Search Samdhi Al Comnpaete incornplete Typa Laat Hama First Hana Confidential and Proprietary to Humana In
134. ter date Click Reports Enter the date of the report needed select Report TYPE Click Retrieve Reports UPLOAD STATUS REPORT l m Upload Report CO E Select the report file sis UPR Camp lipteodem LE E Applies GECCE ia Temana Tjik iaf Tania Ob 04 2044 08 09 2011 Application Status report seth ci mnakaa ialaran Diamar a l H oar ee i 7 Thang Far ror Frinyins CDS Contacts Liptisted a Fame i cos Commets Weh Fahad ts Opd Neds Hund ehh pelicasoni Qeecripticn Last Mama FirstName Phere ie TAC Cn et CA ESLRH Geia PF ii ESIN CEZA OAN In Pro ve Hele f j I Sut citind Delo ed application n Dji eE Seles Steel IRAD ae ie COON COCR ANN OTONOMI In Pa Fesik kaa tem Pistia Pr Haaa Wi rar Dai i2 Tam Ara OE mes Fa Plank SESE COST ON In fra FiFi Reports Please select Date range for reports Report retrieval box From Date To Date 0513 2011 08 10 2011 Select Report Type Application Status Report Retrieve Reports Select a Application Status Report File No reports available Cancel E Oo F G 4 FOMTALEAADIW2FCE inah capein HOE 234 3333 5 z SCOS CONTACTS WHICH FAILED TO UPDATE i 2 i UplnadContactiescription LastName FiniName PhoneNumber 16 L SUCCESSFULLY UPLOADED APPUCATIONS il li ApplacatontD Application Type Laithaene Finttiame i 1S PeMTALBLAD IWIFCE Pai nuh capti HOE dd Danial Proventa Plis PPO lt IF APPUCATIONS WHICH FAILED TO UPLOAD Li
135. that the Medicare health plan will release my information to Medicare and other plans as is necessary for treatment payment and health care operations also acknowledge that Humana will release my information including prescription drug event data to Medicare who may release it for research and other purposes which follow all applicable Federal statutes and regulations The information on this enrollment form is correct to the best of my knowledge understand that if intentionally provide false information on this form will be disenrolled frorn the plan understand that my signature or the signature of the person authorized to act on behalf of the individual under the laws of the State where the individual resides on this application means that have read and understand the contents of this application If signed by an authorized individual as described above the signature certifies that 1 this person is authorized under State law to complete this enrollment and 2 documentation of this authority is available upon request by Hurnana or Medicare have Read and Understand the Statements Above Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 44 07 23 2012 Application Review Individual Application O B MMO New Member Orientation Would you like to attend NMO Reason for not attending 5elect Reason Yes O Mo G Not Interested Electronic
136. the witness information has been entered in the appropriate fields you are ready to call for verification Verification It is Humana policy to complete a verification on all applications Verification for a group application is done by mail the M O option is automatically selected CVE VB MO Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 86 07 23 2012 New Member Orientation New member orientation will go into more detail about how to use your plan and give valuable info on different programs that we have select Yes or No If no you must use the drop down and select a reason why This will write to the Smart Pad in CDS NMO New Member Orientation Reason for not attending MMO Would vou like to attend MMO ee select Reasor Yes Ono o O E Mot Interested Mo Seminars Available for Location Selected Member has already attended Member Undecided Other Selecting Yes will not enroll the member in an orientation class Materials Used select all the materials that you used during your Appointment This information will write to the Smart Pad in CDS Materials Used MAPO Power Point Presentation MA Power Point Presentation POP Power Point Presentation Summary of Benefits Walue Added Services Benefit and Provider Leaflet Compensation sheet Confidential and Proprietary to Humana Inc For Train
137. thorization Form Application Type Language English Spanish A Member Authorization form can be Plan Type completed as the last step of the Sine weer individual application or as a stand AEF Group Individual alone form OSB Member Authorization SOA FSB REAL For Me Medicare Supplement Single Husband and Wife Member Authorization At the end of the Individual application a Do you want to complete an authorization form pop up box will appear Select YES The Member Authorization form will open with all the member information pre filled 4 Member Authorization Client Infonneiiean County Dae of Birth Pd Lasi Name First Marne T f Pemanent Address 1 Pormanom Address 2 2 t City Fiale Tip County Phone sisi u Buum a poss e ave at oe oe a ft ie i ee D eee d Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 113 07 23 2012 Member Authorization Form e If the member is over 65 enter the name the same way it would appear on the Medicare ID card e The address must be a residential address not a PO box e The Medicare claim number field is optional If you enter the Medicare claim number you must enter it twice for validation e If an e mail address is add the member is agreeing to receive Information about other products via email A Member Authorization lent Information Co
138. tion plan coverage costs Medicare will pay all or part of your plan premium If Medicare pays only a portion of this premium we will bill you for the amount that Medicare does nat cover Payrnent Options Social Security Benefit Check Deduction If the premium deduction is 200 01 the SSA option is not allowed Railroad Retirement Board Benefit Check Deduction You must currently be receiving a Railroad Retireme Coupon Book Credit Card Mame O Visa O MasterCard Discover eg Card Number Expiration Date O Automatic Withdrawal Bank Name Routing Number Account Number Your Hame 1001 1234 Oak Anytown USA Account Type itiiti Checking Savings DOLLARS FOR HeeJQSB789 OOOL2IGSE7H9 41004 ABA Check Routing Number Account Number x Nu b234 56789 O00L23456789 4 Return to Plan Determination Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 34 07 23 2012 Payment Tab Individual Application Zero premium plans Even with a Zero premium plan a payment option must be selected This will be stored on file and only used if it is determined there is a late enrollment penalty Demographics Medicare Card Clinical Qualifying Plan Specific Payment Agent Only Monthly Premium Your monthly payment for your CarePlus Plan will be no more than poo payment option still needed a PLEASE SELECT A PREMIUM PAYM
139. tment Current Date Time 09 18 2009 03 45 Verify appointment date if not the same day PLEASE READ THIS IMPORTANT INFORMATION By signing this form you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initiated above The person that will be discussing plan options with you is either employed or contracted by a Medicare health plan Release of Information Signing this form does NOT affect your current enrollment nor will it enroll you ina Medicare Advantage Plan Prescription Drug Plan or other Medicare plan Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 21 10 01 2012 Scope of Appointment Form Summary sign the application Note you the agent must sign the SOA Signature signature of Applicant or Authorized Legal Representative including valid Power of Attorney Legal Guardian ete Client Sign ANI J EN a T EN eee F UlICK IN tNe CIFCI O signature Date Agent Sign Capture Signature Once you click OK on capture signature the algnature Date i signature date will populate il Clear Signature Witness Sign signature Date signature of Witness Translator or Person assisting in completion of form other than agent Witness Translator Last Name Witness Translator First Name Relation lf a witness is signing you must enter the name and relationship of the witness If v
140. to look for missing information 1 Please select a subsequent payment option e If something is missing an error page will appear showing what needs to be corrected ES Agreement MER A Online Service Agreement Agreement with Humana This agreement is between you and Humana Inc on behalf of its affiliates Consent to Electronic Transactions l the User and Humana acknowledge and agree to the following provisions 1 To conduct this enrollment and any changes made to this enrollment information through the use of an electronic transaction which will be verified by the use of an electronic signature This consent to conduct an electronic transaction only applies to enrollment services gt i i The Online Service 3 That may request that this Agreement be terminated If terminated paper access to enrollment Ag reement states the services and forms will be distributed at no cost to me if an address phone number and a contact name are provided to a Humana representative member agrees to the only 4 That may request a paper copy of this recorded transaction enrollment the box must be For More Information checked Humana 500 W Main Street Louisville KY 40202 Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 129 07 23 2012 Free Standing Benefits FSB Review and Sign A Free Standing Benefits Summary Client Information fip Code Cou
141. to the question Medicare Card Clinical Qualifying Plan Specific Payment Agent Only nce enrolled will you have other medical health coverage OYes ONo If yas complete the following The PPO plan to the left Carrier Mame Carrier Address 1 Carrier Address 2 Oooo ES i ena ses coverage end stage renal ni at disease and additional ti td a __ i tid prescription drug coverage Once enrolled will you or your spouse if married work Oves ONo Do you have end stage renal disease Oves Oro Again changes to future plans will cause this section If you do not need regular dialysis any more or have had a successful kidney transplant please attach a note or records to change as needed from your doctor showing you do not need dialysis or have had a successful kidney transplant Some individuals may have other drug coverage including private insurance TRICARE federal employee health benefits OYes f OM coverage VA benefits or state pharmaceutical assistance programs Will you have other prescription drug coverage in addition to this plan for which you are applying If yes please list your other coverage and your identification ID number s for this coverage Name of other coverage Group for this coverage ID for this coverage RX BIN RXPCN Carrier Phone optional fields Carrer Phone Nurmber CHEE TEREA REREH Name of chosen Primary Care Physician PCP clinic or health center
142. ts discussed Mark all products you talked about during your visit This should match your Scope of Appointment Demographics Medicare Card Other Coverage Medical Questions Payment Agent Only Office Use Only Plan Representative REP Affinity Partner GR por Beef Protec y Be Date Agency Agency ID Affinity Partner Location BN TA JEEE Doo i i Agent Code MGA Code Referring Broker Mame Referring Broker SAN mE ee ee E Campaign 0305046921 All health insurance policies sold to the applicant which are still in force if none write NONE Company Type Doo E All health insurance policies sold to the applicant with in the past five years which are no longer in force if none write NONE Company Type Source Sub Source House Member Type sub Type Disposition Disposition 2 Disposition 3 Sold MedSupp Good Service Products Discussed Please select ALL that apply Ri PoP O MAM AFP D C MedSupp C Other Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 63 07 23 2012 Affinity Partners Affinity Partner VWWalhart Affinity Partner Locatian search StorelD WalMart Was this Sale originated from a WalMart Store Leave Store ID Blank Store ID select the correct Office Use Only select None Plan Representative Location REP Affinity Partner Boston Rebecca TC CL v Date Health Plan One Health Pla
143. tton on the laptop screen The client can tap on OK on the tablet or Signature signature of applicant or authorized legal representative incluaing valid Power of Attorney Legal Guardian ete Once the signature Is captured a Client Client Sign Signature Captured message will appear TE and the client s 2 ae 101200 Signature Date will automatically be entered into the field Click on the OK button to go to ee E the next step ok Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 84 07 23 2012 Capturing Signatures Witness Usually a witness signature will not be necessary for the application Some situations where a witness signature would be captured are when e The applicant wishes for someone else family member friend to sign the application as a witness e The applicant cannot physically completely sign their name i e they sign an X on the tablet By clicking the Witness Translator Sign radio button the Capture Client Signature and Clear Client Signature buttons change to Capture Witness Signature and Clear Witness Signature respectively The signature tablet is ready for the witness signature If the witness does not like the appearance of their signature they can try again after the signature on the tablet screen is cleared The signature can be cleared in one of two ways e Tab clear on the signature pad
144. unty Date of Birth BULLITT KY v 10 45 1943 Last Mame First Mame Mi Z Permanent Address 1 Permanent Address 2 ty Lip County Phone LT Be mae Optional Email Address By providing vour ernailiphone number vou consent to receiving information via email or phone po cen Medicare Claim Number Re Enter Medicare Claim Number Male O Female ee oe Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 114 07 23 2012 Member Authorization Form There are 3 sections that the client can request information on e Product Selection e Advocacy and Volunteer e Future Products Note the client is required to select at least one but not limited to just one They can select as many as they like Yes ld like to receive information on the following non ealth related products and services please check all that apply W Life Insurance Products Other Insurance Products fincluding hospital accident long term care and disability Annuities All ofthe above Put a next to the options the member would like Information about Yes Id like to receve information about please check all that apply Opportunities to volunteer in community activities Pending state or federal legislation _ Grassroots advocacy organizations including opportunities to join such organizations Wellness products and programs All
145. ution for fraud The undersigned applicant certifies that the applicant has read or had read to him or her the completed application and that the applicant realizes that any false statement or misrepresentation in the application may result in loss of coverage under the policy The applicant further acknowledges receipt of the currently available Outline of Coverage and the Choosing a Medigap Policy A Guide to Health Insurance for People with Medicare publication l have read and understand the statements above Return to Application e Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 66 07 23 2012 Medicare Supplement Application Service Agreement You must read the agreement to the member and have them Place a ggn the box then click Next Ee Agreement a Online Service Agreement Agreement with Humana This agreement is between you and Humana Inc on behalf of its affiliates Consent to Electronic Transactions I the User and Humana acknowledge and agree to the following provisions 1 To conduct this enrollment and any changes made to this enrollment information through the use of an electronic transaction which will be verified by the use of an electronic signature 2 This consent to conduct an electronic transaction only applies to enrollment services 3 That may request that this Agreement be terminated If terminated paper access to enr
146. ve including valid Power of Attorney Legal Guardian etc Click the radio button to active signature pad Signature Date j j cren Capture Signature signature of Vitness Translator or Person assisting in completion of form other than agent Witness Translator signature signature Date Clear Signature Witness Translator Last Mame Witness Translator First Mame Relation SSS If you are the authorized legal representative POA you must sign above and provide the following information Last Name First Mame hl Address Address Apti Click return if an City ae Tip Error was found Pp Click save and close Phone Relation to Applicant whencompleted O DoS Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 118 07 23 2012 Free Standing Benefits FSB A free standing benefit is a benefit that does not require enrollment to a Mediocre Advantage plan Application Type Language English Spanish Plan Type Humana Care Plus Select the Plan Type AEF dividu The select the FSB radio O Group a nde button to enroll in a OSB Member Authorization free standing benefit SOA FSB REAL For Me Medicare Supplement Single Husband and Wife Click Create Blank Application to enroll anew member someone not downloaded Click Enroll next to the name of the down loaded contact to get the application to pre fill
147. will automatically be entered into the field Click on the OK button to go to ee E the next step ok Confidential and Proprietary to Humana Inc For Training Purposes Only Not CMS Approved Humana Internal Use only 96 07 23 2012 You will now be prompted to enter the Witness First Name Witness Last Name and Relation to Applicant in the fields under the witness signature Witness Translator Last Mame Witness Translator First Mame Pt pO Relation pO lf someone is acting as the POA that person will sign in place of the member and their personal information will need to be entered in the fields at the bottom of the application You as the agent are not the authorized representative If you are the authorized legal representative you must sign above and provide the following information Last Name First Mare tll po pO Address1 Address Doo y Doo City tate Zip DO J U ee ee Phone Relation to Applicant Pp GR BN VYerifler Verification Reason for not verifying When both signatures have been captured and the witness information has been entered in the appropriate fields you are ready to call for verification Verification It is Humana policy to complete a verification on all applications Verification for an AEF application is the O B option and it is automatically selected O B Rik de rh hod I a 1 ie 1 Confidential and Proprietary to Humana In
148. y Partner Locatian search StorelD WalMart Was this Sale originated from a WalMart Store Leave Store ID Blank Store ID select the correct Office Use Only select None Plan Representative Location REP Affinity Partner Boston Rebecca TC CL v Date Health Plan One Health Plan Services Referring Agent Agent Afinity TID Healthy American Hershend Farm Entertainment Humana Guidance Center Attachments OaAmoo1 OAM C AMOo06 Indiana Farm Gureau Insphere Kelse lf the affinity partner is Wal mart the store number must be listed If you don t know the Store ID Click on the Search Store ID button Leave ID blank and click Search e Enter State and City of the store WalMart Was this Sale originated from a WalMart Store State cy Ean If the affinity partner is a Humana Guidance Center the location must be entered Affinity Partner Health Compare Health Flan One Health Flan Services Healthy American Hershend Fam Entertainment Humana Guidance Center W Indiana Farm Bureau Insphere Affinity Partner Humana Guide Affinity Partner Location le Confidential and Proprietary to Humana Inc Humana Internal Use only 19 STOREID ADDR1 CTY 10613 g646 Skillman Street Dallas TH 10615 2257 S 100th Street West Allis WI 40616 227 Willow Bend Crystal MN 0617 11316 Montgomery Road Cincinnati OH 10618 T666 Nob Hill Road Tamarac FL 10619 12100 E Colonial Dr Orl

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