Request for Services from a Nonparticipating Provider (PPO/HMO)

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HMSA strives to maintain a comprehensive network of participating providers so you can get the care you need. To receive the most from your health plan benefits, we encourage members to get care from HMSA participating providers. However, we know that’s not always possible. In those cases, PPO and HMO members may ask HMSA to cover services from an out-of-network (nonparticipating) provider at an in-network (participating) level of benefits. To find participating providers who can provide the service you need, you can use the Find a Doctor tool.

You are encouraged to work with your PCP or referring provider first to find a suitable participating provider and take advantage of your health plan’s travel assistance program, if applicable. If no suitable option is available, you should work with your PCP or referring provider to request nonparticipating specialty care as needed. PCPs or referring providers will complete and submit precertification request forms to HMSA on behalf of members. Requests must be made before the services are received. If services aren’t approved first, HMO members won’t be covered for out-of-network services and PPO members will be covered for these services only at the out-of-network level.

To get approval, you must be diagnosed with a condition or disease requiring specialty care. Also, HMSA either:

  • Doesn’t have a participating provider who can provide the appropriate health care services for your condition or disease.
  • Cannot provide reasonable access to a participating provider who can give the appropriate health care services without unreasonable travel or delay.

For more information on requesting services from a nonparticipating provider, please call the phone numbers on the back of your HMSA membership card or 1-800-776-4672 toll-free.

This request applies only to PPO and HMO members accessing services within the State of Hawaii; it doesn’t include Medicare, Medicaid, HMSA Plan for Federal Employees or Federal Employee Plan Program.