An organization determination is HMSA’s decision about if we can cover the medical care or service you request, or how much you’ll pay for a service. Requesting an organization determination before you receive the medical care or service is called prior authorization.
Standard organization determination: Generally we’ll give you an answer within seven calendar days after we receive your request. If we need more than seven days to respond, we’ll tell you in writing.
Expedited organization determination: Under certain circumstances, we’ll respond within 72 hours after we receive your request. Expedited determination only applies when the standard seven-day time frame for a prior authorization could cause serious harm to your health or your ability to function. If your doctor asks for an expedited determination, we’ll automatically agree to respond in 72 hours. If you ask for an expedited determination without your doctor’s support, we’ll decide if your health condition requires an expedited determination.
Instructions
To request an organization determination for a medical service, call HMSA Customer Relations at 808-948-6000 or 1-800-660-4672 seven days a week, 8 a.m. to 8 p.m. For TTY, call 711.
Or you can submit the HMSA Pre-certification Request Form, which we’ll use in our formal review. Because we need codes and other health system information, your doctor is the best person to complete the form.
Preparing the form
- You or your doctor can fill out and submit the form.
- Make sure the form includes your name, telephone numbers, birth date, and HMSA subscriber number.
- To avoid any delays, attach (or have your doctor attach) supporting documents from your medical record, according to HMSA’s medical policy.
- Fax the required documents to 808-944-5611 or mail them to:
HMSA
Medical Management Department
P. O. Box 2001
Honolulu, HI 96805-2001
Withdrawing a Request
You or your doctor can withdraw the request for an organization determination at any time before HMSA makes a decision. To request a withdrawal, call Customer Relations at 808-948-6000 or 1-800-660-4672.
Disagreeing with HMSA’s decision
You may disagree with any of our decisions, including our decision to:
- Deny an expedited organization determination request.
- Not provide or pay for a service.
- Discontinue or reduce a previously authorized treatment.
If you disagree with any of these or other parts of the process, you have the right to appeal.
For process or status questions, you or your doctor can call Customer Relations at 808-948-6000 or 1-800-660-4672 seven days a week, 8 a.m. to 8 p.m. For TTY, call 711.