Health Maintenance Organization Administrative Review

Services rendered to HMSA’s HMO commercial and Medicare Advantage (HMO) members by out-of-state providers or in-state nonparticipating providers are not eligible for benefit coverage unless HMSA has authorized the services through HMSA’s Administrative Review process prior to services being rendered. Before referring an HMO member to these providers, the member’s PCP or other health center physician must submit a request for Administrative Review and receive HMSA’s approval.

The Administrative Review Process

The PCP, another health center physician, or health center administrator must complete the Precertification Request Form [PDF] or or submit online referrals in iExchange:

• Check the box at the top of the form marked HMO Administrative Review.
• Complete the requested information about the referring and servicing providers and the diagnosis and procedure codes.
• Provide the rationale for referring the patient to a nonparticipating or out-of-state provider.
• Send the completed form by fax or mail to the Precertification Unit.
• Retroactive requests need to be received within 15 days from the start date of requested services.
• Online referrals are entered in iExchange. Log on to HHIN+ (Hawaii Health Information Network).

After reviewing the request, HMSA staff will issue an approval or denial notification letter to the PCP with copies to the member and servicing provider no later than 14 days of HMSA’s receipt of all pertinent information.

If HMSA needs additional information to process the request, the provider is given 45 days to submit the information for Commercial HMO. Medicare Advantage (HMO) plans do not allow extensions for additional information.

The status of approval or denial can be displayed in iExchange, and providers may upload additional information online using iExchange (instead of fax or mail.)

Services Also Requiring Precertification

If the services being proposed for Administrative Review also require precertification (see Services That Require Precertification for HMO commercial, or Precertification Requirements – Medicare Advantage Plans, the boxes for both Precertification Request and HMO Administrative Review can be checked on the same Precertification Request Form. Precertification of a service does not guarantee that HMSA will approve of the service being performed by a nonparticipating or out-of-state provider. In iExchange please enter the precertification request first, and then enter the referral.

Services Not Requiring Administrative Review

An Administrative Review is not required:

• For urgent/emergent in-state or out-of-state services.
• For mental health/substance abuse services performed in-state by a participating provider or out-of-state by a BlueCard provider. Services rendered by nonparticipating providers are not covered.

NOTE: Mental health or substance abuse residential care facility services outside the state of Hawaii require precertification.

Revision History