All participating and most nonparticipating providers in Hawaii will file claims for you. If your nonparticipating provider in Hawaii or an out-of-state provider doesn’t file for you, you can submit a claim to us for payment. There’s no form for you to fill out. Just send HMSA the statement prepared by your nonparticipating or out-of-state provider and make sure the statement includes all of the information listed below.
For timely claims processing, please submit your claim within a year from the last day on which you received services. Submit the claim to HMSA at the appropriate address.
Submitting your request for reimbursement
Copies of the provider statement and any supporting documents you send to HMSA should be clear and legible, with your HMSA subscriber number written on each page. Please keep the originals for your records, because documents you submit to HMSA won’t be returned to you.
We require a provider statement in order to process your claim for services. The provider statement must include all of the information below:
- Provider’s full name, phone number, and address.
- Patient’s name and birth date.
- Date(s) of services.
- Date(s) of the injury or start of illness.
- The charge for each service. Cost for services that are listed in a foreign currency will be converted to U.S. currency at the exchange rate on the date of service.
- Description of each service.
- Diagnosis or type of illness or injury.
- Where the service was received (for example, an office, outpatient clinic, or hospital).
- Information about other health coverage you may have.
Please include a cover letter with the documents you submit. Your cover letter must include:
- The name, date of birth, address, and HMSA membership number of the person that received the service or supply.
- A daytime phone number where you can be reached.
- A brief description of the service and/or why the service was needed.
- Your signature.
Note: Claims must be received within a year from the last day on which services were received. For HMSA’s Plan for Federal Employees, claims will be accepted until December 31 of the year after the year service was received. Refer to the Federal plan brochure for more information.