Frequently Asked Questions: Medical Policies

How are medical policies developed?

HMSA’s Medical Management Department is responsible for developing and updating medical policies. HMSA medical directors, assisted by medical policy analysts, review new technologies and procedures based on governmental and other research conducted nationally. They examine peer-reviewed journals and other material and verify that appropriate regulatory approvals (e.g., FDA approval) or recommendations have been made. In addition, they compare their findings with analyses by the national Blue Cross and Blue Shield Association.

Although HMSA’s medical directors may refer to national practice standards when determining benefit policies, they depart from the standards, when necessary, based on Hawaii’s unique healthcare environment. The medical directors consider whether procedures or technologies are medically appropriate and effective, what utilization measures may be necessary, and whether the services will provide quality care for HMSA members.

Once medical policies are developed, they are approved by HMSA medical directors as a body and then reviewed by various quality oversight committees that include practicing physicians in the community. Only after all reviews are complete are the policies announced and posted in the Provider E-Library.

How often are medical policies reviewed and updated?

In accordance with guidelines of the National Committee for Quality Assurance (NCQA), HMSA medical policies are reviewed annually and updated as needed. In some cases, when there are new codes, new study results, new indications or contraindications, or when clarification is needed, policies may be updated more frequently.

How can practitioners provide input regarding a specific medical policy?

External consultants who are practicing physicians in the community are asked to review and provide input when medical policies are established or updated.

Other physicians who wish to provide input on HMSA medical policies may do so at any time by writing to:

Medical Policy Review

HMSA – Medical Management Dept.

P.O. Box 2081

Honolulu, HI  96805

When offering input on a medical policy, please be sure to enclose documentation, including articles from peer-reviewed journals, literature references, CDC or FDA recommendations, and pertinent codes, as well as a clear, concise recommendation about how a policy might be changed or modified. Input will be reviewed and considered by HMSA Medical Directors.

Revision History