Organization Determination (Request for Prior Authorization)

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An organization determination is HMSA’s decision about whether we’ll cover the medical care or service you request, or how much you have to pay for a service. When you request an organization determination before you receive the medical care or services we call this a Prior Authorization.

Standard coverage decision – Generally we will give you an answer within 14 calendar days after we receive your request. We can take up to 14 more calendar days, but if we do extend our time to respond, we will tell you in writing.

Fast coverage decision – Under certain circumstances we will respond within 72 hours after we receive your request. These fast coverage decisions only apply when the request is for a Prior Authorization and the standard decision deadline could cause serious harm to your health or your ability to function. If your doctor asks for a fast coverage decision we will automatically agree to respond in 72 hours. If you ask for a fast decision without your doctor’s support, we will decide whether your health requires a fast coverage decision.

Instructions

To request an organization determination for a medical service, please call HMSA Customer Relations at 808-948-6000 on Oahu or 1-800-660-4672 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.

Or you can submit the HMSA Pre-certification Request Form, which we will use in our formal review. Because we need codes and other health system information, your physician is the best person to complete the form.

Preparing the form

  • Fill out your name, telephone numbers, birth date, 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 fax the required documents to 808-944-5611 on Oahu or mail it to:
    HMSA
    Medical Management Department
    P. O. Box 2001
    Honolulu, HI 96805-2001

Disagreeing with HMSA's decision

You may disagree with any of our decisions including: our decision to deny a fast coverage request; our decision to not provide or pay for a service; our decision to discontinue or reduce a previously authorized treatment; or some other part of the process. If you disagree, you have the right to appeal.

For process or status questions, members and/or physicians can contact Customer Service at 808-948-6000 on Oahu or 1-800-660-4672 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.