Payment Determination Criteria

HMSA applies payment determination criteria to determine if a service of supply is a covered benefit under your plan. Please see your Guide to Benefits for a complete description of payment determination criteria and requirements under Hawaii law. You can learn more about Hawaii’s law on medical necessity on the Hawaii State Legislature website.

To be covered, the service or supply must meet all of the following:

  • 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 in improving 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    • If no professional standards of care exist, or if they exist but are outdated or contradictory, then by expert opinion.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 medical condition being treated, compared to alternative health interventions or no intervention. Cost-effective doesn’t necessarily mean the lowest price.

Services that aren’t known to be effective in improving health outcomes include services that are experimental or investigational.

The fact that a physician may prescribe, order, recommend or approve a service or supply doesn’t by itself mean that the service or supply meets the payment determination criteria, even if the service or supply is listed as covered in your Guide to Benefits.

Participating providers may not charge you for services or supplies that don’t meet payment determination criteria unless you sign and give the provider a written acknowledgment of financial responsibility specific to the service or supply before services are rendered.

More than one service or supply may be appropriate to diagnose or treat your condition. In that case, HMSA reserves the right to cover only the least costly service or supply.

You may ask your physician to contact us before you receive the care to determine if the services you need meet our payment determination criteria or are excluded from coverage.