Payment Determination Criteria

Covered services must meet all of the following payment determination criteria. The treatment, service, or supply must be:

• For the purpose of treating a medical condition.
• The most appropriate delivery or level of service, considering potential benefits and harms to the patient.
• Known to be effective to improve health outcomes, provided that:
  • Effectiveness is determined first by scientific evidence.
  • If no scientific evidence exists, then by professional standards of care.
  • If no professional standards of care exist or if they exist but are outdated or contradictory, then by expert opinion.
• Cost effective for the treated medical condition compared to alternative health interventions, including no intervention. For purposes of this paragraph, cost effective doesn’t necessarily mean the lowest price.

Services that are not known to be effective in improving health outcomes include, but are not limited to, services which are experimental or investigational.
 

Services that Do Not Meet HMSA's Payment Determination Criteria

Select services are considered noncovered services. Claims submitted for these services will be denied and the provider must not bill or collect charges from the patient for these services unless a written acknowledgement of financial responsibility, specific to the service, is obtained from the patient before services are rendered. A list of codes is contained in the following tables:

Codes That Do Not Meet Payment Determination Criteria list

Codes That Do Not Meet Payment Determination Criteria list: QUEST Integration

Definitions of terms and additional information about payment determination criteria are contained in the Patients' Bill of Rights and Responsibilities, Hawaii Revised Statutes section 432E-1.4 , or Hawaii Administrative Rules, HAR 1700.1-42 for QUEST Integration. The current language of this statutory provision will be provided on request. Requests should be submitted to HMSA's Customer Relations department.
 
The fact that a physician may prescribe, order, recommend, or approve a service or supply doesn’t necessarily mean that the service or supply meets payment determination criteria, even if it’s listed as a plan benefit.

Participating providers may not bill or collect charges from HMSA members for services or supplies that don’t meet HMSA's payment determination criteria unless a written acknowledgement of financial responsibility, specific to the service, is obtained from the patient before services are rendered.
 
For non-QUEST members, participating providers may, however, bill the patient for services or supplies that are excluded from coverage without obtaining a written acknowledgement of financial responsibility from the patient.
 
More than one procedure, service, or supply may be appropriate for the diagnosis and treatment of a condition. In that case, we reserve the right to approve only the least costly treatment, service, or supply.
 

Request for Clinical Review

HMSA will review submitted clinical review request(s) for a procedure, service, or supply before rendering care for exceptional situations listed below. Submissions which don’t fall within these guidelines will be returned with no review:

1. Treatment isn’t for a medical condition.
2. Treatment isn’t considered standard of care for that member’s condition.
3. Treatment is being performed at a higher setting.
4. Treatment hasn’t shown to be effective or has limited scientific evidence of improving health outcomes. (Please submit appropriate literature or articles with request.)
5. Treatment appears cosmetic in nature.
6. Treatment may be considered investigational.
7. Treatment is being used outside the prescribed service guidelines.
8. Treatment doesn’t meet HMSA’s medical policy criteria.
9. Treatment isn’t a benefit of the member’s plan.
10. Treatment may not be the most cost effective compared to alternative health interventions. Cost effective doesn’t necessarily mean the cheapest.
11. Service that’s on the Codes That Do Not Meet Payment Determination Criteria list. (Please submit appropriate literature or articles with request.)

You may submit the request using the clinical review form. A request form that’s incomplete or missing information will be returned. If you’re unsure if a service meets the above, you may call HMSA at 808-948-6464.

Please consider the following when submitting a request for review:

• This process only applies to services that don’t require prior authorization by HMSA.
• If your request is in relation to a service covered within a posted medical policy, it will be returned. Please ensure all applicable policies pertaining to your payment determination request have been reviewed before submission.  
• Submit appropriate literature/articles to be considered during our review process, when appropriate.
• For post service reviews, your request will be returned to follow the claim review process if a claim has already been submitted.

A review of services does not guarantee payment. Reimbursement of claims is subject to the terms and limitations of member’s plan, plan benefits, eligibility at the time of service, provider contracts, and appropriate coding and billing practices.