Workers’ Compensation

Under the provisions of HMSA plans, medical claims for which workers’ compensation coverage may be available are not covered. These provisions apply to claims for services provided in connection with an injury or illness that may be work related.

Claims for a work-related injury or illness must be submitted to the patient’s employer’s workers’ compensation carrier. Providers are reminded to file claims to the appropriate carrier promptly. Claims that are denied due to untimely filing are not the responsibility of the member or the member’s plan.

If HMSA pays benefits for services that should have been billed to workers’ compensation, HMSA will seek reimbursement from the participating provider.

Medicare Advantage plans follow the same (Medicare Secondary Payer) MSP guidelines as Medicare for workers’ compensation cases.

Payment Denial by Workers’ Compensation Carrier

If a claim is denied or controverted by the workers’ compensation carrier, either the patient or the provider may notify HMSA of such decision. We’ll then send the non-QUEST Integration member a Workers’ Compensation Questionnaire form and an Injury/Illness Report Form and ask that the forms be completed and returned to us with a copy of the letter from the workers’ compensation carrier denying or controverting the claim. Information regarding TPL Workers’ COMP is available at HMSA.com If You’re Injured in an Accident.

Although the forms are sent by HMSA to the member when an investigation is opened, members sometimes forget to return the completed forms in a timely manner. A provider may assist HMSA with its information gathering by copying the forms and asking the member to complete the forms in his or her office. The provider may then submit the unaltered, signed and completed forms to HMSA to facilitate the investigation. The forms should be sent to HMSA as a claim attachment.

Claims Payment

Upon receipt of the required documents and confirmation that workers’ compensation benefits are not available or that a claim is controverted, HMSA will process a claim related to the injury or illness in accordance with the benefits of the member’s plan.

Notes:

All claims paid by HMSA are subject to member eligibility at the time of service, HMSA’s guidelines for payment determination, and the provisions and limitations of the member’s plan.

Participating providers should help HMSA by adhering to filing requirements of third party workers’ compensation carriers for the proper coordination of benefits. For help with workers’ compensation filing requirements such as treatment plans, contact the member’s workers’ compensation carrier or the Department of Labor: labor.hawaii.gov/dcd/wc-links/.

The member is responsible for denials due to managed care restrictions or treatment plan denials.

If the member doesn’t provide the information about the injury or illness that’s requested by HMSA, claims for related services may be delayed or denied.

Member Questions

Members with questions regarding HMSA’s third party rules should refer to their HMSA Guide to Benefits (GTB). Members may request a copy of their GTB or other assistance from HMSA’s Customer Service Department at:

Member Correspondence

HMSA – Customer Service Department

P.O. Box 860

Honolulu, HI  96808-0860

Revision History