This transparency in coverage will tell you how to submit claims, get preauthorization, and see if a prescription drug is covered. Keep reading for more about these topics and additional information about your HMSA Affordable Care Act (ACA) plan.
Seeing nonparticipating providers
Does it cost more to see a nonparticipating provider?
What if I see a nonparticipating provider for an emergency?
The copayment for covered emergency services is the same as a participating provider copayment, plus you have to pay the difference between the actual charge and HMSA’s payment. Read your Guide to Benefits to learn more.
Who will submit my claims to HMSA?
All participating and most nonparticipating providers in Hawaii will submit claims for you. If a nonparticipating provider in Hawaii or an out-of-state provider doesn’t submit your claim, you can submit it yourself.
How do I submit a claim on my own?
Send us copies of the provider’s statement and supporting documents with your HMSA subscriber number. Please note that you must submit claims within one year from the last day you received services.
To submit a claim, follow these claims submission instructions and then mail your claim to the appropriate address. If you have questions about submitting claims, call 808-948-6280 or 1-800-648-3190 toll-free.
Paying premiums on time
What happens if I don’t pay a premium?
If you miss premium payments, you must pay your balance in full before your plan’s grace period ends to keep your plan. Grace periods vary depending on your plan and tax credits.
For most ACA plan members:
If you don’t pay your first premium within 20 days of the bill’s due date, your plan will be canceled. If you pay your first premium but miss other payments, the grace period is 30 days after the bill’s due date.
We’ll hold any claims submitted during the grace period. If you pay all missed premiums, these claims will be processed and paid normally. If you don’t pay all missed premiums during the grace period, your plan will be canceled, the claims will be denied, and you’ll have to pay for them.
Avoid missed premium payments by setting up automatic payments.
For ACA plan members with an Advance Premium Tax Credit (APTC):
If you miss a payment, the grace period is 90 days after the bill’s due date. Claims will be paid for covered services received during the first month of the grace period.
If you don’t pay all missed premiums during the grace period, your plan will be canceled, claims received during the second and third month of the grace period will be denied, and you’ll have to pay for them.
Avoid missed premium payments by setting up automatic payments.
Avoiding denied claims
Why did my claim get denied?
There are certain cases when a claim for a service may be denied, even after you’ve received the service and the claim has been paid. Some examples include:
- Using an expired HMSA membership card to get services. If the provider doesn’t verify eligibility over the phone or electronically, the service may be denied when the claim is filed.
- Not getting preauthorization for a service that requires it.
- Getting a service that’s not a benefit of your plan.
- HMSA isn’t your primary health care plan.
How can I avoid denied claims?
The best ways to prevent denials are to pay your premiums on time, talk to your providers about what’s covered before you get services, and know your HMSA plan benefits.
Getting a payment refund
Precertification (also known as preauthorization) is a special approval process that makes sure a certain treatment, procedure, or device meets payment determination criteria before you receive it. These criteria protect member safety, promote appropriate use of services, and help keep health care costs in check. Precertification is also used to evaluate the medical necessity of the service or supply. Since your Guide to Benefits is updated annually, the list of services that require precertification may change during the plan year.
Who handles the precertification process?
Some HMSA participating providers request approval for you, but others may not. Call HMSA or your doctor to find out who should request approval. If you don’t get approval, your plan may not pay for the service or product. Please read your Guide to Benefits for a complete description of payment determination criteria and requirements under Hawaii law.
What if I see a nonparticipating provider?
Doctors, specialists, and other health care providers outside of HMSA’s network are nonparticipating providers. If you don’t get approval before you receive services from a nonparticipating provider, benefits may be partially or entirely denied and you may have to pay more.
How long will it take to review a precertification request?
If your request isn’t urgent, we’ll respond within 15 days after receiving it. If we need more time to review it, we’ll let you know why we’re extending our review and when we expect to make a decision. If we need more information from you or your provider, we’ll give you at least 45 days to provide it.
Requesting prescription drugs
How do I know which drugs are covered?
How do I request a drug that’s not on my plan’s formulary?
If your drug isn’t on your formulary, you may qualify for an exception if you have a condition that didn’t respond to formulary alternatives or if your doctor says you should stay on your current drug.
If this applies to you, work with your doctor to ask for an exception, which is called a coverage determination. If you need a quick response for health reasons, your doctor can make an expedited request. Learn how to make a coverage determination request.
How long will it take to review my request?
After we receive your doctor’s statement, you’ll receive a decision within 72 hours for standard requests and 24 hours for expedited requests.
Understanding your Report to Member
What’s a Report to Member?
After we receive and process a claim for services, you’ll get a statement called a Report to Member. This report shows how much we paid for services and the amount you’re responsible for. The report is an explanation of benefits and isn’t a bill.
Please take time to read your Report to Member and call us if you see any inaccuracies. Learn how to read your Report to Member.
Coordinating your benefits
If I have more than one health plan, which one pays first?
If you have more than one health plan (for example, you have a plan from your employer and you’re a dependent on your spouse’s plan), HMSA will coordinate benefits for you. This means we’ll apply rules to determine which plan pays first and which pays second.
Let us know if you have other coverage such as group insurance, other group benefit plans, Medicare or other government benefits, or health care benefits in your automobile insurance.
Reviewing your dental plan benefits
How do I see the benefits of my HMSA dental plan?
Learn more about your dental plan benefits at hmsadental.com.