If non-contracted providers have questions about how their claim was processed, how it was paid, or why it was denied, they may appeal and ask us to review the claim.
Providers must make their appeal within 60 days from HMSA’s original decision to deny the claim. If the provider’s request for reconsideration is filed beyond the 60th day and the provider doesn’t submit a good reason for filing late, we’ll forward the request to the independent review entity to dismiss.
Payment disputes must be made within 120 days. If non-contracted providers would like their claim reviewed, here are some of their options. For more information that’s not included below, please see the HMSA Akamai Advantage® Frequently Asked Questions (FAQs).
Appealing a Processed Claim
If you disagree with our decision on a claim and want to appeal, please submit an appeal or internal payment dispute in writing.
You can appeal for medical necessity or a billing payment dispute, but you may not appeal claim denials for services that are not a plan benefit.
If you’re resubmitting a claim to add or correct information on your original submission, do not include the appeal form. In this situation, follow the CMS-1500 or UB-04 process for claims resubmission.
Submission of an Appeal or Internal Payment Dispute
Examples of Appeals for
|Examples of Bill Payment Disputes|
Denials based on payment determination criteria not being met.
|Bundling and unbundling of codes when two or more CPT codes are billed on the same claim.|
Denials based on medical policy criteria not being met.
|Reassignment or reduction in code levels after clinical review.|
Please submit a written appeal or payment dispute. You may use your own form or complete the HMSA Akamai Advantage Non-contracted Provider Appeal and Payment Dispute Request form.
For appeals, please file the HMSA Akamai Advantage Non-contracted Provider Waiver of Liability Statement form. We cannot review your appeal unless you include this signed form.
For payment disputes, the waiver of liability (WOL) statement is requested, but non-completion of the WOL won’t affect our decision.
Submit your request and completed provider waiver of liability statement to:
HMSA Member Advocacy and Appeals
P.O. Box 1958
Honolulu, Hi 96805-1958
Or fax it to 952-7546 on Oahu.
If you’re not satisfied with our appeal or payment dispute decision and want to pursue the matter further, please request the applicable external review process.
Appeal External Review
If you don’t agree with MAXIMUS's decision, you can request an external review with the administrative law judge. For more information on the Medicare appeals process, visit medicareappeal.com.
Payment Dispute External Review
If you went through every internal dispute process and still think you should be reimbursed, you can file a complaint at 1 (800) Medicare [1 (800) 633-4227] in addition to any other actions that you feel are appropriate. The Centers for Medicare & Medicaid Services (CMS) doesn’t offer advice to providers on their potential rights in a payment dispute.
To learn more, see page 35 of the MA Payment Guide for Out of Network Payments at cms.gov. Search for “MA Payment Guide for Out of Network Payments.”
If you believe a claim was incorrectly paid or processed, call:
Or write to:
Research and Correspondence
HMSA - Customer Relations
P.O. Box 860
Honolulu, HI 96808-0860
We’ll review the information we have on file. If we determine that we incorrectly processed the claim, we’ll reprocess it.
One of our medical directors will decide if medical or clinical reviews are needed to determine medical necessity. You can also ask to speak with a medical director.
If you subsequently provide additional information or have unresolved questions, we’ll follow-up with you.
To view the previous version of this page, click on the link below:
|Rev#:||Date:||Nature of Change:|
|1.0||12/20/2017||Per Naming convention update - revise title from Akamai Advantage Non-Contracted Provider Appeals to HMSA Akamai Advantage Non-Contracted Provider Appeals.|
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