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 in writing of our decision within 72 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

For process or status questions, members and/or physicians can contact Customer Service at the numbers listed below. 1 (808) 948-6000 on Oahu or toll-free from the Neighbor Islands and U.S. Mainland at 1 (800) 776-4672. Telephone representatives are available seven days a week, 8 a.m. to 8 p.m. TTY users call 711.