QUEST Integration - Referrals

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

PCPs must manage their patients' care including making referrals to specialists. A PCP referral is required for most services provided by specialists. PCPs and specialists should keep records of referrals in patient records.

Referrals for specialty care should be made to providers in HMSA's QUEST Integration network. If referral to a provider outside the HMSA QUEST Integration network is necessary, prior authorization (precertification) must first be obtained. Surgeons should consider this when arranging for anesthesia or assistant surgeon service.

Prior authorization (precertification) can be requested by submitting the HMSA Precertification Request Form [PDF] or by using HHIN+. For more information regarding precertification, please refer to QUEST Integration - Precertification - Medical.

A list of participating providers is available and updated periodically. For a copy, please call QUEST Integration Provider Service at 948-6486 on Oahu or toll-free from the Neighbor Islands at 1 (800) 440-0640. The list also is available online through HMSA's web page at www.hmsa.com.

Referrals are not needed in an emergency. See additional information about Emergency Services below.

Emergency Services

• Emergency care does not require PCP referral, even if the services are performed by a non-participating provider.
• The provider should notify the patient's PCP within 24 hours or the first working day after the services were rendered so that the PCP is aware of the care rendered to the patient.
• Claims must be submitted with the emergency indicator checked to identify emergency services.

Revision History