Current Required Prior Authorization Code List

Page contents:

• Prior Authorization Requirements
• Reference Materials for Prior Authorization Requirements
• How to Submit Prior Authorization Request
• HMSA Utilization Management Partnership

Prior Authorization Requirements

Please follow the link below to access the most current prior authorization / precertification requirements, including applicable medical policies and a searchable code list

https://hmsa.policytransparency.com

Please note:

• This list excludes pharmacy drug authorization requirements. You may contact CVS to determine if authorization is required at 1-855-240-0543 (Commercial), 1-855-344-0930 (Medicare) or 1-855-220-5732 (QUEST).
• The following HMSA plans require prior authorization for ALL services, not just the services on this list, for all in-state non-participating providers or for all out-of-state services except for urgent/emergent services.
  • Commercial HMO
  • HMSA QUEST
• For air ambulance services (A0430, A0435), prior authorization is required for in-state non-urgent transports and all out-of-state transports to and from the state of Hawaii.
• This list only indicates whether prior authorization is required for a service code. It does not confirm if the service is a covered benefit under a member’s plan. Providers must verify eligibility and benefits separately.
• Per MQD requirements, all Electronic Visit Verification (EVV) services must be prior authorized. The list of EVV HCPCS codes and modifiers for personal care agency and home health agency services can be found in the QI-2605 (Replaces QI-2125) EVV Service Codes and Modifiers Table [PDF] on the MQD site.
• For QUEST transportation services, please refer to the Provider Resource Center (PRC) for detailed requirements:
  • Ground Transportation – Non-Emergent
  • Interisland Air Transportation
  • Out-of-State Travel

If you have additional questions on whether prior authorization is required, please contact HMSA at 808-948-6464 (Oahu), toll-free 1-800-344-9122 (Neighbor Islands) or toll free 1-800-877-5394 (US Mainland).

Reference Materials for Prior Authorization Requirements

The Required Prior Authorization Code List is provided as a reference to help determine whether a procedure code requires prior authorization. For additional information on coverage criteria, documentation, and payment determination, please refer to the following resources:

• HMSA Medical Policies
• Claim Documentation Requirements
• Codes That Do Not Meet Payment Determination Criteria
• QUEST Integration – Codes That Do Not Meet Payment Determination Criteria
• Place of Service (POS) Codes
• QUEST Integration – Place of Service Codes

How to Submit Prior Authorization Request

1. Online submission platform

   • Prior authorization requests may be submitted electronically by providers via online submission platform by going to the Preauthorization page in Hawaii Healthcare Information Network HHIN+.
   • It allows users to check the status of their requests and receive notifications of updates or approvals.
   • For online submissions that require prior authorization, auto approval rules (AARs) have been set up to automatically approve requests if the providers’ entries meet the criteria. If the electronic requests are not approved by the AARs, providers will be notified that their requests will be reviewed by the Medical Management staff.
   • Please visit HHIN+ Documents and Information if you need additional details or support.

2. Other methods

   • Most forms can be completed directly on your computer and printed for faxing or mailing to HMSA. Please use this Forms Index to locate the correct form for the requesting services.

   • For some services, a unique form specific to the service must be completed, as indicated in the associated medical policy. If a medical policy doesn’t refer to a form specific to the service, complete the generic HMSA Prior Authorization Request Form [PDF].

     Complete the form and mail, email, or fax it to HMSA at:

     Mail:

     Precertification Request

     HMSA - Medical Management Department

     P.O. Box 2001

     Honolulu, HI  96805

     Email:

     precertification@hmsa.com

     Fax:

     808-944-5611

     Prior authorization requests for behavioral health services should be submitted to HMSA’s delegate, Magellan Hawaii, using the provided phone or fax numbers:

     • Phone: 808-695-7700 (local) or 1-855-856-0578
     • Fax: 808-695-7799 or 855-539-5880

HMSA Utilization Management Partnership

HMSA’s internal Utilization Management program is responsible for managing the utilization of medical services covered by HMSA’s benefit plans. However, certain services may be carved out from this program and managed by third-party vendors because they require specialized expertise or technology. These delegates include companies that specialize in areas such as behavioral health, radiology, and specialty drugs.

By outsourcing the management of these services to delegates, HMSA can help ensure that members receive high-quality care while also working to control costs. HMSA works closely with these delegates to ensure that they follow evidence-based guidelines and provide services in a cost-effective manner.

The following table summarizes the services for which HMSA delegates manage prior authorization.

Revision History