Seeing Specialists and Other Providers when You’re an HMO Member

As an HMO member, your primary care provider (PCP) coordinates your medical care. Your PCP will refer you to other providers when needed. It is important to ask your PCP if they have arranged for you to see specialists or facilities outside of your health center.

In addition, your PCP will need to obtain prior approval (called an administrative review) from HMSA for services from an HMSA nonparticipating or out-of-state provider. If you receive services from an HMSA nonparticipating or out-of-state provider without prior approval from HMSA, you will be responsible for the total cost of the services, which can be significant.

Note: You do not need coordination from your PCP for emergency services, annual vision exams, Well-Being Connect, HMSA’s Online Care, ob-gyn care from a provider in your health center, and mental health and substance abuse services.

HMO referral process

The referral process is as follows:

  1. Your PCP will look for a physician or facility within your designated health center to treat you.
  2. If a specialty physician or facility isn’t available within your health center, your PCP will refer you to one within the Health Plan Hawaii provider network.
  3. If a specialty physician or facility isn’t available within your Health Plan Hawaii provider network, your PCP will refer you to an HMSA participating physician or facility.
  4. If an HMSA participating provider isn’t available, your PCP refers you to an HMSA nonparticipating provider by obtaining an administrative review from HMSA. Please review the administrative review section below for more information.

When you go to a specialty physician’s office or a facility, you should do both of the following:

  1. Present your HMSA membership card.
  2. Inform the physician or nurse that you’ve been referred by your PCP.

Administrative reviews – when visiting an HMSA nonparticipating or out-of-state provider

Administrative review is an approval process for HMO members that’s required for services to be covered when a provider is located out of state or doesn’t participate with HMSA. In rare circumstances, your PCP may need to refer you to an HMSA nonparticipating or out-of-state physician or facility. This would happen only when a provider with the specialty designation and clinical expertise required to treat your condition is unavailable within the HMSA network of participating providers.

Your PCP must request an administrative review from HMSA before you receive services from an HMSA nonparticipating or out-of-state physician or facility. If your PCP doesn’t get approval before you receive services, you are responsible for the total cost of services.

Referrals to another island

If your PCP refers you to a specialist on another island, you may be eligible for interisland transportation. See Interisland travel for approved medical treatment for more information.

When traveling or living outside of Hawaii

If you’ll be living away from your health center’s service area for more than 90 days, you may enroll in HMSA’s Guest Membership Program, a program that allows you to have a PCP on the Mainland while temporarily living away from home.

If you are traveling outside of Hawaii, please review Does My HMO Plan Cover Services on the Mainland? as well as Emergency and Urgent Care Outside of Hawaii.