If non-contracted providers have questions about how their claim was processed, how it was paid, or why it was denied, they may appeal and ask us to review the claim.
Providers must make their appeal within 65 days from HMSA’s original decision to deny the claim. If the provider’s request for reconsideration is filed beyond the 65th day and the provider doesn’t submit a good reason for filing late, we will dismiss the case for untimely filing.
Payment disputes must be made within 120 days. If non-contracted providers would like their claim reviewed, here are some of their options. For more information that’s not included below, please see the HMSA Akamai Advantage ® Non-Contracted Provider Appeal and Payment Dispute Process Frequently Asked Questions (FAQs).
Internal Appeals and Payment Disputes
Appealing a Processed Claim
If you disagree with our decision on a claim and want to appeal, please submit an appeal request or internal payment dispute request in writing.
You can appeal for medical necessity or a billing payment dispute, but you may not appeal claim denials for services that are not a plan benefit.
If you’re resubmitting a claim to add or correct information on your original submission, do not include the appeal form. In this situation, follow the CMS-1500 or UB-04 process for claims resubmission.
Submission of an Appeal or Internal Payment Dispute
Examples of Appeals for
(Medical Necessity) | Examples of Bill Payment Disputes |
|---|
| Denials based on payment determination criteria not being met | Disagreement to amount a non-contracted provider can collect if member were enrolled in original Medicare. |
| Denials based on medical policy criteria not being met. | |
| Revised decisions for bundling and unbundling of codes and disputed rate of payment. | |
| Reassignment or reduction in code levels after clinical review. | |
Please submit a written appeal or payment dispute requests. You may use your own form or complete the HMSA Akamai Advantage Non-contracted Provider Appeal and Payment Dispute Request form.
For appeals, please file the HMSA Akamai Advantage Non-contracted Provider Waiver of Liability Statement form. We cannot review your appeal request unless you include this signed form.
For payment disputes, the waiver of liability (WOL) statement is requested, but non-completion of the WOL won’t affect our decision.
Submit your request and completed provider waiver of liability statement to:
HMSA Member Advocacy and Appeals
P.O. Box 1958
Honolulu, Hi 96805-1958
Or fax it to 1 (808) 952-7546 on Oahu.
Appeals
- We’ll review the appeal and any additional information you send to us.
- We'll notify you of our decision within 60 days of receiving your appeal.
- If we agree with your appeal, we’ll pay the claim within 60 days from the date we received the appeal.
- If we don’t agree with your appeal, we’ll send our decision in writing and case referral to MAXIMUS Federal Services, Inc., the independent review entity and CMS contractor that reviews appeals for Medicare plans.
- If MAXIMUS also doesn’t agree with your appeal, you’ll receive a letter that explains your right to further appeal.
- If MAXIMUS overturned HMSA’s determination, we’ll pay the claim within 30 days of MAXIMUS’s letter
Payment Disputes
- We’ll review your dispute and any additional information that you submit to support your claim.
- We’ll notify you of our decision within 30 days. If we agree with your dispute, we’ll pay you within 30 days. If we don’t agree with your dispute, we’ll send you a letter that explains your right to an independent payment dispute decision
External Appeals and Payment Disputes
If you’re not satisfied with our appeal or payment dispute decision and want to pursue the matter further, please request the applicable external review process.
Appeal External Review
If you don’t agree with MAXIMUS's decision, you can request an external review with the administrative law judge. For more information on the Medicare appeals process, visit medicareappeal.com.
Payment Dispute External Review
If you went through every internal dispute process and still think you should be reimbursed, you can file a complaint at 1 (800) Medicare [1 (800) 633-4227] in addition to any other actions that you feel are appropriate. The Centers for Medicare & Medicaid Services (CMS) doesn’t offer advice to providers on their potential rights in a payment dispute.
To learn more, see page 35 of the MA Payment Guide for Out of Network Payments at cms.gov. Search for “MA Payment Guide for Out of Network Payments.”
Questions About Processed Claims
If you believe a claim was incorrectly paid or processed, call:
- Oahu: 1 (808) 948-6330
- Neighbor Islands: 1 (800) 790-4672 toll-free
Or write to:
Research and Correspondence
HMSA - Provider Relations
P.O. Box 860
Honolulu, HI 96808-0860
We’ll review the information we have on file. If we determine that we incorrectly processed the claim, we’ll reprocess it.
One of our medical directors will decide if medical or clinical reviews are needed to determine medical necessity. You can also ask to speak with a medical director.
If you subsequently provide additional information or have unresolved questions, we’ll follow-up with you.
