Health Maintenance Organization Precertification Requirements

HMSA's Commercial HMO and Medicare Advantage (PPO/HMO) plans require precertification of certain services and procedures. See Services That Require Precertification for HMO commercial or Precertification Requirements - Medicare Advantage Plans.

When a service that requires precertification also requires a referral, please indicate the name of the referring physician on the precertification request. HMSA is not able to review your request for precertification without this information. Send your precertification request to the Precertification Unit (HMSA Directory - Provider Resources).

Medicare Advantage (HMO) members are required to receive medical services from their primary care provider (PCP) or a health center physician. A referral is needed when a member seeks non-emergent or non-urgent treatment outside of the health center. See Medicare Advantage (HMO) Referrals or Health Maintenance Organization Administrative Review (Medicare Advantage (HMO) Referrals).

Required components of precertification request:

Complete all elements of the precertification request form [PDF]and attach the relevant documentation as required by the relevant medical policy. If any of the information necessary to review the request is not included, HMSA's determination will be delayed.

Revision History