Health Plan Hawaii (HPH)/HMO Referral

Health Plan Hawaii (HPH)/HMO members are expected to receive medical services from their primary care provider (PCP) or another health center provider whenever possible. Generally, a referral is needed when a member seeks non-emergent or non-urgent treatment outside of the health center.

Using their professional judgment, providers should refer members as follows:

• Refer to other providers within their health center.
• Refer to providers in other health centers.
• Refer to providers or facilities that have contracted with Health Plan Hawaii.
• Refer to other HMSA participating providers.

If referring to other HMSA participating providers, the referring physician must send the referral in writing or by phone. Documentation of the referral is required to be part of the patient's medical record.

HMSA nonparticipating providers and out-of-State referrals require administrative review. Health center physicians who refer patients to HMSA nonparticipating providers and out of state must submit an HMO Administrative Review request and receive approval prior to making the referral.

Services for Which a Referral is Not Required

The following services, when performed outside the member's health center, do not require a referral:

• Emergency care, including ambulance and outpatient claims related to an emergency room service.
• Anesthesia and related services rendered on the same date as the surgery when the member's PCP or another physician within the member's health center admits the member for surgery.
• Behavioral health (inpatient and outpatient) and alcohol and substance abuse treatment. This includes services rendered by applied behavior analysis providers.
• Routine diagnostic services ordered by the health center physician or authorized physician.
• Off-site lab/radiology services, including the ambulance, when an inpatient member requires lab or radiology services that are only available at another location.
• Hospital admission in Hawaii when the attending physician is the member's PCP or another physician within the member's health center.
• Surgicenter (ASC), if attending physician is a physician within the member's health center.
• X-ray services, including technical and professional components, when ordered by a health center physician/PCP, or when a referral (direct or associated with an inpatient admission) already has been made. Note: Screening mammograms do not require referrals.
• Routine vision exam. A referral is not required if the member's health center does not include an ophthalmologist and/or optometrist.
• Urgent care, including services rendered at participating Urgent Care centers, Minute-Clinics and Queen's Medical Center After Hours Center providers.
• Inpatient care, including all physician services when a referral (direct or associated to an inpatient admission) already has been made and when the inpatient admission was for emergency care.
• Breast pump purchase, from HMSA participating providers.
• COVID-19 related services (through the federal public health emergency period).
• Vaccines, including Hep A, influenza, measles, mumps, and rubella (MMR), and Shingrix vaccines.
• Contraceptive counseling, when rendered by participating pharmacy provider.
• Immunizations, effective with service date on or after Jan. 1, 2020 when rendered by a participating provider.
• Military providers.
• Newborn care.
• Well-woman exams, including annual gynecological exams. (Well-Woman Exams can be rendered by an HMSA HMO participating provider. A non-participating provider with HMSA’s HMO product, cannot render a Well-Woman Exam without a referral)

Procedures Requiring Precertification and Referral

Some medical procedures and treatments (e.g., home IV pain management therapy) require precertification. If a service that requires a referral also requires precertification, please send both request forms at the same time so HMSA can process the requests concurrently.

Revision History