Concurrent Review

If HMSA determines that a member's inpatient admission no longer meets the requirements of coverage by the plan based on a concurrent review, the provider can request a review of determination.

Concurrent Review

HMSA decides when to conduct a review of the medical necessity for ongoing care during a member's inpatient stay based on local and national benchmarks and input from the community.

Disputing a concurrent review decision

A provider who disagrees with a concurrent review decision regarding the medical appropriateness of a member's inpatient confinement can appeal to a medical director at HMSA's Behavioral Health Services QUEST Integration (Magellan Hawaiʻi) for services relating to QUEST members. If services are for commercial, Federal Employee Program (Federal Employees Health Benefits (FEHB) and Postal Service Health Benefits (PSHB), Fed 87 members, or HMSA Plan for Postal Service Employees, contact a medical director at HMSA's Behavioral Health Services - Commercial, FEP, Fed 87 (Magellan Hawaiʻi).
If a determination is made by the Magellan Hawaiʻi behavioral health medical director to uphold the concurrent review decision, the provider may appeal further, following the steps described in Appealing a Precertification Denial.

Availability of a Physician Reviewer or Behavioral Health Reviewer

A provider also may request to speak with the physician reviewer or the behavioral health reviewer who made the original decision, or with another reviewer who was not involved in making the original determination. The reviewer may request additional information from the provider.

To initiate an inquiry, contact HMSA's Behavioral Health Services QUEST (Magellan Hawaiʻi) or HMSA's Behavioral Health Services - Commercial, FEP, Fed 87 (Magellan Hawaiʻi) accordingly.

Revision History