Please read Prior approval for medical services (precertification) for more information regarding precertification.
Your participating provider obtains precertification
If you’re under the care of an HMSA participating physician, the physician will:
- Obtain approval for you, and
- Accept any penalties for failure to obtain approval.
HMSA’s participating providers will submit a request for precertification before providing a medical service or device that’s subject to precertification. If an HMSA participating provider doesn’t submit a request, but chooses to provide the service or device, the provider will accept any penalties for failure to request approval.
When you’re responsible to obtain precertification
If you’re under the care of one of the following types of providers, you’re responsible for ensuring that your provider submits documentation to HMSA for a precertification approval:
- A BlueCard PPO provider on the Mainland or in another country,
- A BlueCard participating provider on the Mainland or in another country, or
- A nonparticipating provider.
If precertification approval isn’t obtained, your claim will be denied and you will be responsible for the total cost of the medical service or device.
To get started, please print the precertification form. Ask your provider to complete the form and submit it to HMSA with supporting documentation according to the medical policy relevant to your request. For PPO members, please note that your portion of the cost for services rendered by a nonparticipating provider may be substantially higher than if you were seen by a participating provider.
How to request precertification
To obtain precertification, your provider must complete the HMSA Precertification Request Form and mail, fax, or email it to HMSA at:
6th Floor, HMSA’s Medical Management Department
P.O. Box 2001
Honolulu, HI 96805-2001
If you’d like to check on the status of your precertification request, please call HMSA Customer Relations.
Your provider must include the following information with the precertification request:
- Patient information. The patient’s name, address, date of birth, gender, HMSA subscriber number, and information about any other insurance coverage available. If the patient is a dependent on the medical plan, the subscriber’s name on the plan must also be included.
- Physician or provider information.The name, address, telephone number, fax number, and HMSA provider number of the provider(s) of the service or medical device.
- Applicable clinical information about the proposed service or equipment. Details should be included about the patient’s current illness, the primary and secondary diagnoses, the proposed treatment or service, and the frequency of services and expected duration of treatment. The provider should review the medical policy applicable to the service being requested to determine if additional documentation should be submitted with the request.
- HMO Requirements. If the patient is an HMO member, the member’s primary care provider (PCP) directs all care. If the PCP recommends that the patient visit a nonparticipating provider or a provider outside of Hawaii for a service that requires precertification, the PCP must indicate the need for administrative review on the precertification form. Only one request is needed.
For additional important information, we encourage you to read: