If you disagree with the processing, payment, or non-payment of a claim, you may request a review. Requests for review must be made within 65 days from your receipt of HMSA's original decision to deny or pay the claim. Below are your options if you would like your claim reviewed. Additional information about appeals may be found in HMSA's Participating Physician Agreement.
Inquiries About Processed Claims
You may initiate an inquiry by contacting Provider Correspondence.
A Provider Services representative will review the information on file. If the information indicates that the claim was processed incorrectly, the claim will be reprocessed.
Any determination involving medical or clinical review will be made by an HMSA medical director. You may ask to speak to a medical director, who will be available for discussion at your request.
If you provide additional information or have unresolved questions, a follow-up inquiry may be initiated.
Internal Appeals
An internal appeals process is available to providers who have a Participating Provider Agreement with HMSA.
Appealing a Precertification Determination
Precertification denials may be appealed. For information on submitting a precertification appeal, refer to Physician Appealing a Precertification Denial.
Appealing a Processed Claim
You may appeal a claim determination by submitting a written internal appeal request.
HMSA will review the written request and any additional information you submit and notify you of its decision no later than 60 days after receiving your appeal.
If HMSA decides in your favor, payment will be made within 30 days of the notification of the decision.
If the determination is not in your favor, you may request arbitration.
How to Submit an Internal Appeal
Please submit your written request for an internal appeal by fax or mail to the
Appeals Unit.
Your written request can include:
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Your reason for disagreeing with the decision.
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Detailed justification for reconsideration.
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A copy of the member's benefit in question.
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Citation of additional scientific findings.
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Additional medical records.
Arbitration
Arbitration is available to physicians who have a Participating Provider Agreement with HMSA.
If you are dissatisfied with the internal appeal decision you must request an arbitration within 60 calendar days of the date of the decision. Arbitration is final and binding. Refer to
Arbitration.
