QUEST Integration – HMSA Medical Policies, Formularies and Related Information

Original Effective Date:

07/01/2012

Current Effective Date:

01/01/2015

The material appearing in this section is specifically tailored to health care providers and their staffs. The documents described below include medical terms and other information that may be unfamiliar to some patients. As always, patients who have questions about their treatment should contact their health care providers.

Medical policies

Like other health plans in Hawaii and on the Mainland, HMSA develops detailed benefit-coverage guidelines regarding certain medical treatments and drugs. The guidelines are included in HMSA’s QUEST Integration – Medical Policies, and QUEST Integration Medical Policies Pre-certification, which provide physicians with information they can use to determine when benefit coverage for a particular service is available for their patients.

Formularies

HMSA’s drug formularies are lists of medications that are covered under HMSA drug plans. Pharmacy and Formulary – Benefits and Copayments in the HMSA eLibrary can be accessed to find the HMSA QUEST Integration Formulary [PDF].

Clinical information requirements

For certain health care services, HMSA asks physicians to submit clinical notes or surgery reports to help HMSA determine that the treatment meets benefit-coverage guidelines. These services are listed in QUEST Integration – Cosmetic Procedures – Claim Documentation Requirements.

Claims-filing procedures

Health care providers follow specific procedures when they submit claims to HMSA. The procedures are summarized in QUEST Integration – Instructions for Completing CMS 1500 Claim Form.

Overpayment procedure

HMSA occasionally pays providers too much for their services. When that happens, providers use the QUEST Integration – Refunding HMSA procedure to refund the overpaid amount to HMSA.

Revision History