If you are appealing an FEP or a Medicare Advantage claim, please refer to Federal Employee Program (FEP) or Medicare Advantage Provider Appeals.
If your claim is related to QUEST claim, please refer to QUEST Integration - Provider Reconsiderations, Grievances, and Appeals Process.
For the purposes of this document, Physician is defined as a Medical Doctor or as a Doctor of Osteopathy. If you are not a physician, please refer to Non-Physician Appealing a Precertified Denial.
Physician Inquiries
If a precertification request is denied, you may request a further explanation of the clinical reasons for the denial by calling HMSA at 948-6464 (Oahu) or 1 (800) 344-6122 (Neighbor Islands) to speak to the medical director who made the determination.
Internal Appeals
You or your agent may appeal HMSA's precertification determination. The appeal musts be in writing (unless you are requesting an expedited appeal) and made within one year of your or your agent's receipt of the original determination. Only the primary care physician or the treating physician has the authority to act as the member’s representative without a completed representative form. To appeal a precertification denial, both you and the member must complete the CMS-1696 Appointment of Representative form and submit it with your appeal.
If the appeal pertains to a clinical issue, you may request a review by an Independent Review Organization (IRO).
You must complete and submit the Form to Appeal a Precertification Denial or submit a written appeal request to be recognized as an appeal and must include the following information:
- Patient's name.
- HMSA member ID number.
- Physician's name.
- Physician's identification number.
- Description of the facts related to the appeal request.
- Why you believe HMSA's decision is in error.
- A copy of HMSA's denial letter.
- Any written comments, documents, clinical records and journal articles not considered in the precertification review.
Expedited Appeal
You may request an expedited appeal if application of the precertification (30 days) time period may:
- Seriously jeopardize your patient's life or health,
- Seriously jeopardize your patient's ability to gain maximum functioning, or
- Subject your patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.
HMSA will respond to an expedited appeal within 72 hours of HMSA's receipt of the request. You will be notified by phone of the final internal determination, followed by a letter.
You or your agent may request an expedited appeal by calling Member Advocacy & Appeals at 948-5090 (Oahu) or 1 (800) 462-2085 (Neighbor Islands). (The oral request must be followed by a written request.) A request for an expedited appeal may also be made in writing to the HMSA Member Advocacy & Appeals address or fax number shown below.
HMSA Member Advocacy & Appeals
P.O. Box 1958
Honolulu, HI 96805-1958
OR
Fax: (808) 952-7546 or (808) 948-8206
OR
Email: appeals@hmsa.com
Standard Appeal
HMSA will respond to an appeal as expeditiously as your patient's health requires, but no later than 30 calendar days from HMSA's receipt of the request.
The appeal must be in writing and must be submitted to HMSA at the address or fax number shown above.
The appeal request, case documentation and any additional information provided will be reviewed. You and your patient will be notified in writing of the final internal determination.
The appeal request, case documentation and any additional information provided will be reviewed. Both the Physician and the member will be notified in writing of the final internal appeal decision.
EXTERNAL APPEALS
Arbitration
Arbitration is the external review process available to Physicians who have a Participating Physician Agreement with HMSA.
If you are dissatisfied with the final internal determination and wish to pursue the matter further, you must request arbitration within 60 calendar days after the date of our letter notifying you of the final internal determination. Arbitration is final and binding. For more information, refer to Arbitration.
