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Organization Determination (Request for Prior Authorization)

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An organization determination is HMSA’s initial decision about whether we’ll provide the medical care or service you request, or pay for a service you’ve received.

Standard decision – The timeframe we have to make a decision after we receive your request depends on whether you’ve already received your care or service, or you’re waiting to receive your care or service. Refer to the Evidence of Coverage for detailed information about the standard decision process for an organization determination.

Fast decision – We must notify you in writing of our decision within 72 hours, if you or your doctor believes that waiting for a standard decision could seriously harm your health or your ability to function. Refer to the Evidence of Coverage for detailed information about the fast decision process for an organization determination.

Instructions

To request an organization determination for a medical service, please call HMSA Customer Relations at 808-948-6000 on Oahu or 1-800-776-4672 toll-free on the Neighbor Islands or Mainland. Telephone representatives are available seven days a week, 8 a.m. to 8 p.m. TTY users, call 711.

Medical care or service organization determination requests – This form, the HMSA Pre-certification Request Form, is part of the formal review process for requesting that a particular medical service or treatment be covered by HMSA. Because of the need for codes and other health system information, you’ll need your physician’s assistance to complete it.

Please print out the form and complete your portion. Ask your physician to complete the remainder and mail it to HMSA’s Medical Management department at the address given below.

  • Fill out your name, telephone numbers, birth date, gender, and HMSA number.
  • Ask your physician to complete and submit the form to HMSA.
  • To avoid any delays, your doctor should attach supporting documentation from your medical record, according to HMSA’s medical policy.
  • Your doctor should mail the required documents to:
    HMSA
    Medical Management Department
    P. O. Box 2001
    Honolulu, HI 96805-2001
  • Your doctor can also fax the completed form to 808-944-5611 on Oahu.

For process or status questions, members and/or physicians can contact Customer Service at the numbers listed below. 808-948-6000 on Oahu or 1-800-776-4672 toll-free from the Neighbor Islands and Mainland. Telephone representatives are available seven days a week, 8 a.m. to 8 p.m. TTY users, call 711.