QUEST Integration – Benefit Information

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

A QUEST Integration Provider Service Representative can give you membership eligibility and general benefit information. Please call 808-948-6486 on Oahu or toll-free from the Neighbor Islands at 1-800-440-0640. Be prepared to provide your QUEST Integration provider number in order to receive information.

For general benefit information, you may also write to:

HMSA – QUEST Integration Operations

P.O. Box 3520

Honolulu, HI  96811-3520

Benefits for a number of procedures, therapies and surgeries must be precertified before payment can be made. The term precertification is the same as prior authorization.

• A list of these procedures that require precertification are 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.
• Information on how to obtain precertifications for most services can be viewed in the QUEST Integration – Precertification – Medical section.
• Information on precertifications for advanced imaging studies can be viewed in the QUEST Integration – Physician Responsibility for Obtaining Precertification of Imaging Studies section.
• Providers can obtain the UM criteria and hard copies of the criteria are made available to providers upon request by phone, fax or mail to QUEST Integration Provider Service.
• Requests for precertification of services after they have been rendered may be considered if submitted within 120 days of the date services were rendered.

To prevent misunderstandings, if you are considering purchasing new equipment or rendering a surgery, therapy or procedure that employs new technology or is investigational in nature, please contact us in advance for a determination of whether the service will be covered.

Please send the appropriate QUEST Integration precertification form to:

HMSA – Medical Management Department

P.O. Box 2001

Honolulu, HI  96805

- or -

Fax: 808-944-5611

The forms should provide the following information essential to process your request in a timely manner.

• The patient’s name and HMSA QUEST Integration member ID number.
• Diagnosis (ICD-10-CM).
• Details regarding the history of the illness and other therapies attempted.
• The CPT code and description for the procedure, therapy, or surgery you are proposing.
• Your rationale for proposing the service.
• Any supporting information regarding the necessity for and effectiveness of the service.

We will respond within fourteen calendar days of the request with a determination whether the proposed service is eligible for benefits. Determinations on requests that meet the following definition of “urgent” and which are clearly marked as “urgent” will be made within three business days. Scheduling issues are not factors for urgency.

An “urgent” request is defined as one that if processed within the time period applicable to non-urgent care could:

• Seriously jeopardize the member’s life, health or ability to regain maximum function, or
• In the opinion of the member’s treating physician would cause severe pain that cannot be managed without the care that is the subject of the precertification requested.

If a request does not have sufficient information for a determination, providers will be notified, and an additional 14 calendar days will be added to the review time. If the needed information is not received in a timely manner, the request will undergo medical director review with only the available information and may be subject to denial.

Note: Precertification is not a guarantee of payment or approval of charges. Payment is contingent on the patient and provider of service meeting the eligibility criteria of the QUEST Integration Plan. The patient must be eligible under HMSA’s QUEST Integration plan at the time of service, and the provider must be a part of HMSA’s QUEST Integration network of providers. If the provider is not part of HMSA’s QUEST Integration network, an approved precertification for the provider must be on file with HMSA. All provisions of the QUEST Integration plan must apply, including benefit limitations, unless the precertification specifically requested review for a benefit exception.

Revision History