Form Instructions
Organization Determinations
An organization determination is HMSA’s initial decision about whether we
will provide the medical care or service you request, or pay for a service you have
received.
Standard decision – The timeframe we have to make a decision after we receive
your request depends on whether you have already received your care or service,
or you are waiting to receive your care or service. Refer to the Evidence of Coverage
for detailed information about the standard decision process for an organization
determination.
Fast decision – We must notify you by telephone and in writing of our decision
within 24 hours, if you or your doctor believes that waiting for a standard decision
could seriously harm your health or your ability to function. Refer to the Evidence
of Coverage for detailed information about the fast decision process for an organization
determination.
Instructions
To request an organization determination for a medical service, please call Customer
Service directly at the phone numbers listed in
Contact Information. If we can’t respond to your request over the
phone, we have a formal procedure for reviewing your request.
Medical care or service organization determination requests – This form, the Pre-certification
Request Form, is part of the formal review process for requesting that a particular
medical service or treatment be covered by HMSA. Because of the need for codes and
other health system information, you will need your physician’s assistance
to complete it.
Please print out the form and complete your portion. Ask your physician to complete
the remainder and mail it to HMSA’s Medical Management department at the address
given below.
- Fill out your name, telephone numbers, birth date, gender, and HMSA number.
- Ask your physician to complete and submit the form to HMSA.
- To avoid any delays, your doctor should attach supporting documentation from your
medical record, according to HMSA’s medical policy.
- Your doctor should mail the required documents to:
HMSA
Medical Management Department
P. O. Box 2001
Honolulu, HI 96805-2001