QUEST Integration – Precertification – Medical

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

HMSA plans require that certain procedures be precertified. This document lists the services that require precertification and describes designated responsibilities in the precertification process. The term precertification is the same as prior authorization.

• Information on how to obtain precertification for most services can be viewed here, in the QUEST Integration – Benefit Information section of the Provider Handbook.
• A list of procedures that require precertification is included in the QUEST Integration – Services that Require Precertification section of the Provider Handbook.
• More detailed benefit guidelines and precertification instructions for most of these procedures are included in the Benefit Policies section of the Provider Handbook. Information on precertification for advanced imaging studies can be viewed in the QUEST Integration – Physician Responsibility for Obtaining Precertification of Imaging Studies section of the Provider Handbook.
• Providers can obtain the UM criteria, and hard copies are available upon request by phone, fax, or mail through QUEST Integration Provider Service.

Services that Require Precertification

Refer to QUEST Integration – Services that Require Precertification for a list of procedures and drugs requiring precertification. Precertification is not required for emergency services.

Place of Treatment

In addition to the services that require precertification, the place of treatment may require precertification. For example, when a physician believes a procedure should be performed in a more acute setting than is normally deemed appropriate, precertification is required.

Refer to the Place of Treatment – Outpatient Procedures List and Place of Treatment – Office Procedures List for lists of procedures to be performed in office and outpatient settings.

Physician Responsibility

The physician is responsible for obtaining precertification. Refer to HMSA Precertification Request Form [PDF] for a general request. (Other precertification request forms can be found in the QUEST Integration – Forms Index) Precertification request can also be submitted using HHIN+. Written requests should be faxed to 808-944-5611 or mailed to:

Benefit Precertification

HMSA – Medical Management Department

P.O. Box 2001

Honolulu, HI  96805-2001

Required components of a precertification request include, but are not limited to, the following:

• Brief history and physical/clinical notes
• Diagnosis
• Physician’s orders
• Previous treatment
• Planned treatment (including photos and X-rays, if appropriate)
• Expected results
• Supporting information, if necessary

HMSA’s Responsibility

HMSA’s Medical Management Department reviews precertification requests and provides the physician with a determination of benefit coverage within the timeliness standards established by the National Committee for Quality Assurance (NCQA). Please refer to QUEST Integration – Precertification Timeliness Standards.

If a precertification request is denied, physicians may request to discuss or clarify the decision with a physician reviewer by calling HMSA at 808-948-6464 (Oahu) or 1-800-344-6122 (Neighbor Islands), Monday through Friday, from 8 a.m. to 4 p.m., Hawaii Standard Time.

Retroactive Authorization

If a claim was not yet submitted, providers can submit the HMSA Precertification Request Form and all supporting documentation to:

Benefit Precertification

HMSA – Medical Management Department

P.O. Box 2001

Honolulu, HI  96805-2001

Or

Fax: 808-944-5611

If a claim has already been submitted and denied for no precertification, providers will need to submit a corrected claim with all supporting documentation to:

QUEST Integration Claims

P.O. Box 3520

Honolulu, HI  96811-3520

Please note, there is no guarantee that retroactive requests will be authorized.

Facility Responsibility

If the necessary precertification is not obtained but the service is still performed, the facility may be held financially responsible for any unpaid services rendered by the facility.

The facility should first verify with the physician that precertification has been obtained from HMSA. If the physician indicates that precertification is pending, the facility may call HMSA prior to the service being rendered to determine if precertification has been granted.

HMSA’s Precertification Unit can be reached at 808-948-6464 on Oahu or 1-800-344-6122 from the Neighbor Islands, from 8 a.m. to 4 p.m., Monday through Friday. You also may verify precertification by calling a Provider Services Teleservice Representative at 808-948-6330 on Oahu or 1-800-790-4672 from the Neighbor Islands.

Payment Implications

If the physician does not request precertification but the service is still rendered, the claim along with medical records may be reviewed for medical necessity. If services are determined not to meet payment determination criteria, HMSA will not pay for the services. The member may be billed for the non-covered charges only if the member signed a waiver accepting financial responsibility prior to the procedure. (The QUEST Integration Agreement of Financial Responsibility – Medical form [PDF] may be used for this purpose.) Please ensure that HMSA members are fully apprised of their financial responsibility in this situation.

If a physician’s request for precertification is denied, the provider must notify the member of the determination. If the member insists on the service(s) even when informed that it will not be covered by the QUEST Integration plan, the member is responsible for the charges made in connection with the noncovered service. The patient must sign the patient Financial Responsibility form before services are rendered. The term precertification is the same as prior authorization.

Revision History