Two-for-one Benefit Exchange

The following information applies to Preferred Provider Plans, HMO commercial Plans, and the Comprehensive Medical Plan.

Exceeding Benefit Maximums

HMSA's behavioral health services provide intensive case management for specifically identified members. If a member exceeds their benefit maximum for outpatient or inpatient visits, HMSA will work with the behavioral health provider.

Two-for-one Benefit Exchange

Some plans allow members to trade one inpatient day for two outpatient visits. As part of its case management, HMSA will work with the behavioral health provider to coordinate the exchange or flexing of benefits. Two-for-one benefit exchange requires precertification (see Psychological Testing Benefits or Precertification) and may not be traded for psychological or neuropsychological testing services.

Denial of Benefit Payment

After review of a case by a medical director, HMSA will issue any denials of benefit payment for reasons related to appropriateness of care. Appeals of such denials are handled by HMSA (see Appealing Processed Claims).

Revision History