Motor Vehicle Insurance

Under the provisions of HMSA plans, medical claims for which motor vehicle insurance benefits are available are not payable by HMSA. These provisions apply to claims for services furnished in connection with an injury or illness caused by the use, maintenance or operation of a motor vehicle. Claims for such services must be submitted to the motor vehicle insurance carrier in accordance with Hawaii state law and regardless of fault.

Providers are reminded to file claims to the appropriate carrier promptly. Claims that are denied due to untimely filing are not the responsibility of the member or the member's plan.

Examples of situations covered by motor vehicle insurance:

• Injury caused by an automobile accident
• Injury caused while opening or closing an automobile door
• Injury caused while loading or unloading passengers or groceries from an automobile
• Injury caused when children are playing in or on an unattended automobile
• Injury caused by a hit-and-run automobile accident
• Injury to a pedestrian involving an automobile
• Injury to a bicyclist or moped driver involving an automobile
• Injury caused to a person pushing an automobile

If your patient is involved in a motor vehicle-related accident, please submit claims to the motor vehicle insurance carrier first. If HMSA pays benefits for services that should have been billed to a motor vehicle insurance carrier, HMSA will seek reimbursement from the participating provider.

The following are scenarios for which HMSA would review for consideration to apply member’s HMSA plan benefits. Provider would need to submit or resubmit to HMSA as a claim attachment.

• No-fault partial payment—Submit or resubmit no-fault carrier documentation of total payment made reflecting a reason for partial denial (i.e., NF Benefit Exhaust letter).
• No-fault denial—Submit or resubmit no-fault carrier documentation of reason for non-payment (i.e., NF Denial letter, NF Deductible letter, or NF Apportionment letter).
• Provider is disputing HMSA’s denial that care is part of the member’s no-fault case—Submit or resubmit clinical notes for review.
• Provider is disputing HMSA’s denial that they have received reimbursement from the no-fault carrier—Resubmit claim with NF EOB attached to claim confirming which services were reimbursed by the NF carrier.

When the patient exhausts his or her personal injury protection benefits, HMSA will need the following information before any remaining claims relating to the accident can be processed:

• A letter from the motor vehicle insurance carrier indicating that personal injury protection benefits are exhausted
• A detailed list from the motor vehicle insurance carrier, indicating which claims were covered by the motor vehicle insurance carrier. The list must show the date expenses were incurred, the provider of service and the amount paid by motor vehicle insurance.
• A completed Injury/Illness Report Form signed by the injured member. Although the form is sent by HMSA to the member when an investigation is opened, members sometimes forget to return the completed form in a timely manner. A provider may assist HMSA with its information gathering by copying the form and asking the member to complete the form in his or her office. The provider may then submit the unaltered, signed and completed form to HMSA to facilitate the investigation. The form should be sent to HMSA as a claim attachment. Information regarding TPL No-fault is available at HMSA.com, If You're Injured in an Accident.

Once these items are received and the HMSA member record has been updated, HMSA will process remaining claims in accordance with the benefits of the member's plan.

Note: The member is responsible for any cost-sharing payments required by his or her motor vehicle insurance policy. HMSA will not cover personal injury protection cost-sharing payments such as co-payments, denials due to managed care restrictions, or treatment plan denials.

All claims paid by HMSA are subject to member eligibility at the time of service, HMSA's guidelines for payment determination, and the provisions and limitations of the member's plan.

If the member does not provide the information requested by HMSA in connection with the injury or illness, claims for related services may be delayed or denied.

Member Questions

Members with questions regarding HMSA's third party rules should refer to their HMSA Guide to Benefits (GTB). Members may request a copy of their GTB or other information from HMSA's Customer Service Department at:

Member Correspondence, 7th floor
HMSA - Customer Service Department
P.O. Box 860
Honolulu, HI 96808-0860

Revision History