An organization determination is HMSA’s decision about whether we’ll 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 14 days after we receive your request. We may take up to 14 more days, but if we do extend our time 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. These expedited organization determinations only apply when the request is for a prior authorization and using the standard organization determination deadline could cause serious harm to your health or your ability to function. If your doctor asks for an expedited organization determination, we’ll automatically agree to respond in 72 hours. If you ask for an expedited organization determination without your doctor’s support, we’ll decide whether your health condition requires an expedited organization 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 users, 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 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 or mail it to:
  HMSA
  Medical Management Department
  P. O. Box 2001
  Honolulu, HI 96805-2001

Withdrawing a Request

You or your physician 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 physician 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.