When Prior Approval (Precertification) is Denied or Not Requested

When your precertification has been denied

If your precertification request is denied and you disagree with HMSA’s decision, you or your provider may submit an appeal. For further information on appeals, please review How to Appeal an HMSA Decision and your Guide to Benefits.

If precertification is denied, any claim for payment will be denied.

When a claim is denied due to a failure to obtain precertification

HMSA participating providers are responsible for obtaining any required precertification before providing a service or device. If the participating provider didn’t obtain precertification, the provider isn’t allowed to charge you for the service or device.

If you received a service or device from a provider who doesn’t participate with HMSA, you may have to pay the entire charge for the service or device. However, even after the service or device has been provided and the claim for services has been filed and denied, you may ask your provider to submit a precertification request to HMSA. The precertification form and appropriate documentation must be submitted in the same way a precertification is requested prior to a service or device being provided. Please see Submitting a Precertification Request for details.

Agreements of Financial Responsibility

If your HMSA participating provider believes your plan may not cover a service or device, the provider may ask you to sign an Agreement of Financial Responsibility. This agreement requires you to pay the full cost of the service or device. The provider will discuss the form with you before you receive the service or device.

For additional important information, we encourage you to read: