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Payment
Pre-certification
Medical Policies
Appeals
Quality Improvement
Provider Contracting
NPI
Radiology Management

Frequently Asked Questions

Provider Support

How can I verify patient eligibility?

How can I contact my HMSA Field Representative or Coordinator?

How do I submit a change of address?

How can I get a copy of past provider communications?

How can I get an updated listing of Participating Providers?

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How can I verify patient eligibility?


You can verify eligibility by calling HMSA's automated eligibility system, Membership Connection. This easy-to-use system will provide you with information about the member's medical coverage and riders, effective date and more. You can also verify eligibility using HHIN. (See Hawaii Healthcare Information Network (HHIN).)

 


How can I contact my HMSA Field Representative or Coordinator?


Your Field Representative or Coordinator will generally leave a business card with his or her direct phone number during field visits. However, if you do not have the direct number, you may call the Provider Services Administrative Support Unit on Oahu at 948-6820 for assistance in contacting the Field staff. From the Neighbor Islands call 1 (877) 304-4672.

 


How do I submit a change of address?


You can submit a change of address by filling out and submitting the forms in the page below:

Provider Information Forms

 


How can I get a copy of past provider communications?


Provider communications from January 2004 through the current year are available online in the Communication Archive. If you are looking for an older communication, please call a Provider Teleservice Representative or speak to your Field Representative or Coordinator. Communications from 1997 and later years are available. The representative will attempt to locate the communication and fax a copy of it to you. Your request may take several days to process.

 


How can I get an updated listing of Participating Providers?


The most current listings of HMSA Participating Providers for HMSA health plans and riders are available at http://www.hmsa.com/search/providers/default.aspx.

 

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Claims

CMS has announced that some of the new CMS-1500 forms are incorrectly formatted. Will HMSA be able to process claims submitted on these forms?

How can I authorize another person to sign claims on my behalf?

Where should I send my claims?

If I don't understand how a claim was processed, whom should I contact?

How do I include sales tax on a claim?

How can I check the status of a claim?

How do I resubmit a claim?

How do I submit a multi-page claim?

Where can I purchase claim forms locally?

What are the printing requirements for hard-copy claims?

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CMS has announced that some of the new CMS-1500 forms are incorrectly formatted. Will HMSA be able to process claims submitted on these forms?


This issue will not impact HMSA's CMS-1500 acceptance timeline. HMSA will be able to accept the misaligned forms as well as correctly formatted forms.

 


How can I authorize another person to sign claims on my behalf?


Hard-copy claims require the signature of the physician or practitioner providing the service. However, some practitioners prefer to delegate this function to office staff. If this is your intent, please complete an Agent Authorization form and fax it to HMSA at 948-6887 on Oahu.

 


Where should I send my claims?


Different claim types are submitted to various post office boxes.  For example, QUEST, BlueCard and FEP claims are submitted to different post office boxes than the P.O. boxes for HMSA's private business plans claims. To determine the appropriate address for your claims, see the HMSA Directory.

 


If I don't understand how a claim was processed, whom should I contact?


If you would like more information about the processing of a complex claim, call a Provider Teleservice Representative at at 948-6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands.

 

You may also inquire in writing at:

 

Provider Services' Correspondence and Research

HMSA – Room 511

P.O. Box 860

Honolulu, HI 96808-0860

 


How do I include sales tax on a claim?


A provider may choose whether or not to bill for tax. If the provider bills for tax, HCPCS code S9999 should be used to identify the tax. The use of this code applies to both electronic and hard-copy claims.

 


How can I check the status of a claim?


You should begin by carefully reviewing your Report to Provider. Check all pages of the report. If the claim is not shown on the Approved page, it may be on the Adjusted page, the Denied page or the Claims in Process page. If a claim is listed on the Claims in Process page, HMSA has received the claim and is processing it. You do not need to follow up.

 

If you subscribe to the Hawaii Healthcare Information Network (HHIN), you can also check the status of your claims, verify eligibility and do much more. If you do not currently subscribe to HHIN, we encourage you to call the HHIN Help Desk at 948-6446 on Oahu or 1 (800) 760-4672 from the Neighbor Islands.

 


How do I resubmit a claim?


Instructions for resubmitting a claim are available in the Provider E-Library at Resubmissions and Tracers.

 


How do I submit a multi-page claim?


When you are billing for multiple services rendered to the same patient during the same encounter, you may exceed the number of available service lines (six) on the CMS 1500 claim form. When this occurs, you may file a multi-page claim as instructed in Multi - page Claims.

 

 


Where can I purchase claim forms locally?


HMSA has secured special prices from local vendors for CMS 1500 forms for our participating providers. To take advantage  of special rates, mention that you are an HMSA participating provider. Click the link below to view this list of local vendors.

 

CMS 1500 Claim Form - Vendors

 

 


What are the printing requirements for hard-copy claims?


Hard-copy claims should be printed on a clean CMS 1500 claim form.  Keep in mind the following tips when choosing font size and type:

  • Use Arial or Times New Roman fonts.
  • Use font sizes 10 through 12.
  • Use all upper-case letters, rather than a combination of upper- and-lower case letters.  This is the community standard for claims completion.

Note: Dot-matrix printers may produce characters that are fuzzy and difficult to read.  Please review your printed claims to ensure that the printed output is of high quality and the printed characters are sharp and clear. 

 

Although handwritten claims are accepted, such claims must be entered manually, increasing the possibility of keystroke errors and lengthening the processing time for those types of claims. Typed or computer-printed claims are preferred.

 

Do not submit hard-copy claims as follows:

  • With areas highlighted.  The OCR scanner cannot read portions of the claim that are highlighted.
  • Handwritten or printed with red ink. The OCR scanner cannot read portions of the claim that are handwritten or printed in red ink.
  • With lines that are "squeezed" together. Do not double-up or try to squeeze in two lines to conserve space. The OCR scanner cannot read fields with more than one line of information.

For more tips on preparing claims, see Claims Filing Highlights.

 

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BlueCard

How can I identify a BlueCard member?

How can I verify eligibility for out-of-area BlueCard members?

Where should I submit claims for out-of-area BlueCard members?

What if I have a question about the processing of a BlueCard claim?

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How can I identify a BlueCard member?


All Blue Cross and Blue Shield members have membership cards with the Blue Cross and/or Blue Shield service marks. Members who participate in the BlueCard program have a member identification number beginning with a three-character prefix that identifies their home plan. Also, the ID card will have a suitcase logo displayed somewhere on the card. Simply ask the member for his or her ID card, look for the suitcase logo and verify that the ID number begins with three alpha characters.

 


How can I verify eligibility for out-of-area BlueCard members?


First, look for the three-character prefix at the beginning of the member's Blue Cross and/or Blue Shield identification number. Once you have located the prefix, you can call BlueCard Eligibility  at 1 (800) 676-BLUE (2583) or log on to the Hawaii Healthcare Information Network (HHIN) to verify the member's plan and benefits coverage.

 

Note: The automated telephone network is available until 2 p.m. Hawaii time when the Mainland is on daylight-saving time; 3 p.m. when on standard time. HHIN is available for BlueCard eligibility from 1 a.m. until 7 p.m. Hawaii time when the Mainland is on daylight-saving time; 2 p.m. until 8 p.m. when on standard time. 

 

See BlueCard Program for more information about using the automated telephone eligibility system or HHIN.

 


Where should I submit claims for out-of-area BlueCard members?


Claims for out-of-area BlueCard members should be sent directly to:

 

HMSA - BlueCard Program

P.O. Box 2970

Honolulu, HI  96802  

 

Do not collect payment in full for your services. The BlueCard member should be charged only the deductible or copayment owed, if any.

 


What if I have a question about the processing of a BlueCard claim?


Please call a BlueCard Teleservice Representative at 948-6280 on Oahu or 1 (800) 648-3190 from the Neighbor Islands.

 

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Pharmacy

How often is the HMSA Drug Formulary updated?

Where can I find information about HMSA's 65C Plus Prescription Drug Coverage formulary?

How are drugs added to or removed from the formulary?

If the Argus claims processing system is down, how can I determine how much to charge HMSA 65C Plus members for their prescriptions?

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How often is the HMSA Drug Formulary updated?


The HMSA Drug Formulary is updated quarterly, on Jan. 1, Apr. 1, July 1 and Oct. 1, based on recommendations by HMSA's Pharmacy and Therapeutics Committee. The formulary may be accessed in an online (HTML) format or as a Microsoft Excel file. See HMSA's Formulary.

 


Where can I find information about HMSA's 65C Plus Prescription Drug Coverage formulary?


HMSA's 65C Plus Prescription Drug Coverage is HMSA's approved Medicare Part D plan. The plan has its own formulary, Formularies for HMSA's Medicare Part D Plans. Information about the plan is also located at HMSA's 65C Plus Prescription Drug Coverage.

 


How are drugs added to or removed from the formulary?


The HMSA Pharmacy and Therapeutics (P&T) Advisory Committee meets quarterly to provide HMSA with recommendations regarding drug placement on the formulary. The committee also makes recommendations on drug management programs such as therapeutic or clinical protocols and therapeutic interchange. The P&T Committee is composed of practicing physicians and pharmacists in the community who serve voluntarily and are not compensated for their participation.

 

Providers may request that a drug be reviewed for proposed addition to the HMSA formulary if it has been approved by the Food and Drug Administration (FDA) for an indication that would benefit patients in an outpatient setting with a covered medical condition. The drug must also offer a distinct clinical advantage over existing medications of comparable therapeutic effects listed on the formulary. See HMSA Drug Formulary - Introduction for information about how to submit a request.

 


If the Argus claims processing system is down, how can I determine how much to charge HMSA 65C Plus members for their prescriptions?


Drug copayments and other information pertaining to HMSA 65C Plus members are available at HMSA's 65C Plus Prescription Drug Coverage Benefit Information.

 

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Payment

Whom should I contact to find out the eligible charge for a specific item or service?

How do I request review of HMSA's MAC for a specific type of service?

How are fees determined for medical services?

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Whom should I contact to find out the eligible charge for a specific item or service?


Participating providers may submit requests for fee schedules to the HMSA Provider Data Administration department. If a MAC is NOT listed on the HHIN fee schedule website, providers may submit a written request along with a list of codes to:

 

Email:

 

PS_PIU@HMSA.com

or

 

 
Mail:

HMSA
Provider Data Administration, KLCR-PDA
P.O. Box 860, Honolulu, HI  96808-0860

 

or

 

 
Fax: (808) 948-8210

 

When submitting the request for HMSA fee schedules, the request should be formatted with the following information:

 

Provider Name:
Provider ID:
Specialty:
Line of Business (PPO, HMO, QUEST):
 
Procedure Code Modifier HMSA’s MAC
     

 

 

Note:  Codes should be listed individually with modifiers when applicable.

The column, HMSA’s MAC, should be left blank as it will be completed by HMSA staff.

 

Written Requests for 20 codes or less can be submitted via:

  • Fax:  Fax the request to PDA at (808) 948-8210
  • Mail:  Mail the request to the above Provider Data Administration address

 

Written Requests for 21 or more codes can be submitted via:

 

Written requests take approximately 10 to 30 days to process depending on the number of codes requested.

 

If a provider has a specific code request, they can be assisted by our Customer Relations Department by calling 948-6330 on Oahu or 1 (800) 790-4672 toll-free on the Neighbor Islands.

 

 


How do I request review of HMSA's MAC for a specific type of service?


Some HMSA contracts, including the Participating Physician Agreement, include a provision whereby the provider may request fee review if the provider believes HMSA's Maximum Allowable Charge (MAC) for a specific service is not sufficient. If your contract contains this provision (generally found in section 8.4 of the contract), you may request a fee review as discussed in Fee Reviews.

 


How are fees determined for medical services?


HMSA takes several factors into consideration when reviewing its Schedule of Maximum Allowable Charges for the following calendar year. Some of the factors taken into account include:

  • Local economic conditions.  The Consumer Price Index (CPI) for Honolulu is reviewed for a 12-month period from July 1 through June 30 and is compared to the national average for the same period.  HMSA also considers the price index specifically applied to medical services and supplies.
  • Utilization increases. Utilization calculations are also done for the July through June time period for all medical services including physician services, lab and X-ray, various therapeutic services and more.

These factors, along with projected dues income and projected utilization increases associated with new benefit coverage and new technology, are considered, and fee adjustments for the coming year are determined in August and September for implementation in January of the following year.

 

 

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Pre-certification

What services require pre-certification?

How do I obtain pre-certification?

What happens if a service requires pre-certification but I did not pre-certify the service?

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What services require pre-certification?


To prevent misunderstandings, if you are considering purchasing  new equipment or providing a surgery, therapy or procedure that employs  new technology or uses a  new application of existing technology , please contact HMSA in advance for a determination of whether the service will be covered.

 

In addition, various procedures, items and drugs require benefit pre-certification. See Services That Require Precertification for more information.  

 


How do I obtain pre-certification?


Begin by determining whether there is a specific written policy pertaining to the service or item you are planning to provide. (See Services That Require Precertification.) For some services, a unique form specific to the service must be completed, as indicated in the associated benefit policy. Complete the form and mail or fax it to HMSA at:

 

Pre-certification Request, 6th Floor

HMSA - Medical Management Department

P.O. Box 2001

Honolulu, HI  96805

- or -

Fax: (808) 944-5611

 

If a benefit policy does not refer to a form specific to the service, complete the generic HMSA Pre-certification Request Form and mail or fax it to the address above.  

 


What happens if a service requires pre-certification but I did not pre-certify the service?


It depends on the service. Claims for some services will be denied. An example of a denial message is "No payment can be made for this service. The use of an ASC for the surgical procedure performed is not considered appropriate."

 

For other services, processing of the claim may be suspended. The provider will be sent a turnaround document (TAD) or other document requesting additional information (e.g., an operative report, bilirubin counts or clinical notes).

 

If the claim is denied and the provider wishes to have it reviewed for possible payment, the following steps should be taken:

  • Prepare a corrected claim, being sure to note on the top of the claim the specific reason the claim is being resubmitted. See Resubmissions and Tracers for more information. 
  • Enclose with the claim documentation supporting the medical appropriateness of the procedure. Check the Provider E-Library for a specific policy related to the service and read the policy for documentation requirements.
  • Mail the resubmitted claim and attachments to the same P.O. box to which you sent the original claim.  Submitting these items in a separate envelope from other claims - or separating them with a paper clip and a note stating that this is a resubmission - will ensure that the claim is not inadvertently processed as a duplicate of the denied claim.

Once the resubmitted claim and documentation are received, the case will be reviewed for medical appropriateness. If the service is determined to be medically appropriate, the claim will be processed for payment.  If the documentation does not support the medical appropriateness of the service, no payment will be made. The provider may  not bill the member for claims denied because the services are not medically appropriate.

 

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Medical Policies

How are medical policies developed?

How often are medical policies reviewed and updated?

How can practitioners provide input regarding a specific medical policy?

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How are medical policies developed?


HMSA's Medical Management Department is responsible for developing and updating medical policies.  HMSA medical directors, assisted by medical policy analysts, review new technologies and procedures based on governmental and other research conducted nationally.  They examine peer-reviewed journals and other material and verify that appropriate regulatory approvals (e.g., FDA approval) or recommendations have been made.  In addition, they compare their findings with analyses by the national Blue Cross and Blue Shield Association.

 

Although HMSA's medical directors may refer to national practice standards when determining benefit policies, they depart from the standards, when necessary, based on Hawaii's unique healthcare environment.  The medical directors consider whether procedures or technologies are medically appropriate and effective, what utilization measures may be necessary, and whether the services will provide quality care for HMSA members.

 

Once medical policies are developed, they are approved by HMSA medical directors as a body and then reviewed by various quality oversight committees that include practicing physicians in the community.  Only after all reviews are complete are the policies announced and posted in the Provider E-Library.

 


How often are medical policies reviewed and updated?


In accordance with guidelines of the National Committee for Quality Assurance (NCQA), HMSA medical policies are reviewed annually and updated as needed.  In some cases, when there are new codes, new study results, new indications or contraindications, or when clarification is needed, policies may be updated more frequently.

 


How can practitioners provide input regarding a specific medical policy?


External consultants who are practicing physicians in the community are asked to review and provide input when medical policies are established or updated.  

 

Other physicians who wish to provide input on HMSA medical policies may do so at any time by writing to:

 

Medical Policy Review

HMSA - Medical Management Dept.

P.O. Box 2081

Honolulu, HI  96805

 

When offering input on a medical policy, please be sure to enclose documentation, including articles from peer-reviewed journals, literature references, CDC or FDA recommendations, and pertinent codes, as well as a clear, concise recommendation about how a policy might be changed or modified.  Input will be reviewed and considered by HMSA Medical Directors.

 

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Appeals

What steps must a physician take to appeal a processed claim?

What steps must a physician take to appeal the denial of a pre-certification request?

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What steps must a physician take to appeal a processed claim?


The HMSA appeals process for physicians is explained in the Participating Physician Agreement and is also described in Appealing Processed Claims.

 


What steps must a physician take to appeal the denial of a pre-certification request?


The HMSA appeals process for physicians wishing to appeal the denial of a pre-certification is described in Appealing a Pre-Certification Denial.  

 

Note: A facility may not appeal the denial of a pre-certification.  Such an appeal must be made by the member or the member's physician.

 

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Quality Improvement

Does HMSA make quality-improvement visits to physicians' offices?

When do these visits occur?

At what times during the year does Healthcare Effectiveness Data and Information Sett (HEDIS) occur?

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Does HMSA make quality-improvement visits to physicians' offices?


Authorized HMSA Quality Assurance staff routinely contact and/or visit HMSA participating Primary Care Physicians for quality improvement activities. HMSA quality improvement activities include Office Site Evaluations, Medical Record Reviews and Healthcare Effectiveness Data and Information Set ( HEDIS ) audits.  

 


When do these visits occur?


An office-site review occurs when a provider opens a new site, adds another site or relocates to another site. A medical-record review may occur once every three years, and HEDIS (Healthcare Effectiveness Data and Information Set) information is collected from a random selection of HMSA members' charts during specific periods in a calendar year.

 


At what times during the year does Healthcare Effectiveness Data and Information Sett (HEDIS) occur?


HMSA Quality Assurance staff conduct HEDIS data collection for HMSA's Health Plan Hawaii (HPH), Preferred Provider Plan (PPP) and 65C Plus plans in the spring and collect data for The HMSA Plan for QUEST Members in the fall.  

 

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Provider Contracting

Whom do I contact with questions about the Participating Provider Agreement?

Does my agreement apply to new plans introduced by HMSA?

How often must I renew my contract with HMSA?

Can I change my marketing specialty?

How does licensing impact my participating status?

What happens if I decide to terminate my contract with HMSA?

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Whom do I contact with questions about the Participating Provider Agreement?


When you become a participating provider, you are assigned a Provider Services Field Representative or Coordinator who works with you on contracting issues. In that one-to-one relationship, he or she can help answer questions specific to your situation and collaboratively resolve any problems that may arise. For assistance in contacting the Field staff, call 948-5190 on Oahu or 1 (800) 790-4672 from the Neighbor Islands.

 


Does my agreement apply to new plans introduced by HMSA?


Yes. Currently, there are different types of HMSA plans for which you can contract: Preferred Provider Plans (PPP), Health Maintenance Organization (HMO) plans, 65C Plus and other Medicare-based plans and the HMSA Plan for QUEST Members. If a variation is added to one of these basic plan types, your agreement for that plan type will apply. (See HMSA Plans for more information.)

 


How often must I renew my contract with HMSA?


Contracting periods vary depending on your specialty and your preference. Some contracts are evergreen - they renew automatically unless terminated by you or HMSA. Other contracts may have renewal periods of two to five years.

 

In general, the recontracting process is similar for most providers. When an agreement is about to expire, the provider may be sent a draft contract to review, especially if it includes material changes since the last agreement. (Material changes are highlighted on a separate sheet.) After all provider input is received, and revisions made as appropriate, the final agreement is mailed. During this time, the Field Representative or Coordinator is available to help the provider through the recontracting process.

 

If a provider does not renew the agreement by the contract expiration date, HMSA will send a termination notice by certified mail. Following termination of an agreement, a provider may re-enroll as a participating provider. However, if more than 30 days has lapsed since the prior agreement's expiration date, the provider must go through the credentialing process again.

 


Can I change my marketing specialty?


Your licensure, education, board certification and experience determine your marketing specialty, which is listed in HMSA's hard-copy and online provider directories. If you are board-certified in two specialties, you may request to be listed under both specialties in the directories.

 


How does licensing impact my participating status?


State law requires that you have a current, valid license to practice. In addition, licensure is an essential component of your agreement with HMSA.  

 

Both the state and HMSA will notify you when your license is about to expire. HMSA will request that you submit evidence of your license renewal. A reminder will be mailed, as appropriate.

 

If your license lapses, your Participating Provider Agreement with HMSA will be terminated according to the terms of the agreement, via certified mail.

 


What happens if I decide to terminate my contract with HMSA?


Generally, as a participating provider, you may terminate your agreement by giving HMSA at least 60 days' written notice. Providers terminating their agreements bear certain responsibilities related to Continuity of Care for their patients. Also, when providers terminate their agreements, they generally must notify their patients who are HMSA members at least 30 days prior to the termination date.

 

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NPI

What is the NPI?

Who assigns NPIs?

Who is required to obtain an NPI?

Why was the use of NPI established?

Where can I get more information about NPI?

How can I obtain an NPI?

How many NPIs may a healthcare provider obtain?

By what date am I required to have an NPI?

Do I need to share my NPI with HMSA?

What if I receive more than one communication from HMSA requesting my NPI?

Why has HMSA not yet contacted me for my NPI?

What will HMSA do with my NPI?

When does HMSA want me to begin using my NPI?

Will I still need to use my HMSA provider identification number(s)?

What if I use my NPI before HMSA has notified me to do so?

What if I submit hard-copy claims?

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What is the NPI?


The National Provider Identifier (NPI) is a unique, 10-digit identification number used to identify a provider in Health Information Portability and Accountability Act (HIPAA) standard transactions. NPIs are intelligence-free, meaning they do not contain imbedded information about the provider such as practice location, type of service provided, etc.

 


Who assigns NPIs?


The Centers for Medicare and Medicaid Services (CMS) is responsible for oversight and management of the NPI system. CMS has contracted with Fox Systems to operate the National Plan and Provider Enumeration System (NPPES or "the Enumerator"), a computer system that will process applications and updates, ensure the uniqueness of the healthcare provider and generate NPIs.

 


Who is required to obtain an NPI?


All "covered entities" who engage in HIPAA standard transactions must obtain an NPI. Healthcare providers who bill Medicare for their services are required to apply for a national identifier as well. Entities who do not furnish healthcare services (e.g., taxi services, hotels, etc.) are not eligible for NPIs. These HIPAA definitions may offer more clarification:

 

  1. Covered entities are defined as healthcare providers, health plans and healthcare clearinghouses that transmit any health data electronically in connection with a transaction for which the Secretary of Health and Human Services ( HHS ) has adopted a standard (i.e., HIPAA standard transactions).
  2. Healthcare provider is defined in HIPAA regulations as a provider of medical or healthcare services (e.g., physician, qualified psychologist, certified nurse-midwife, hospital, skilled nursing facility, home health agency, etc.) and any other person or organization who furnishes, bills or is paid for healthcare in the normal course of business.
  3. Standard transactions  - such as those found on HHIN - include, but are not limited to: claims and encounter information (837 I/P/D), payment and remittance advice (835), eligibility (270/271) and claims status and inquiry (276).

 


Why was the use of NPI established?


The NPI was established by the Department of Health and Human Services ( HHS ) in 2004 as an Administrative Simplification mandate of HIPAA. The intent is to simplify billing, as providers will have one standard identification number, and speed up coordination of benefits (COB) payments by easing communication among payers.

 


Where can I get more information about NPI?


Use these resources to learn more about NPI:

  1. CMS NPI website: www.cms.hhs.gov/NationalProvIdentStand/
  2. NPPES (the Enumerator) website: https://nppes.cms.hhs.gov/NPPES/Welcome.do
  3. NPPES phone: 1 ( 800) 465-3203; 1 (800) 692-2326 (TTY)

 


How can I obtain an NPI?


Providers can apply for a no-cost NPI three ways:

  1. Complete the online application at the NPPES website: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.
  2. Call 1 (800) 465-3203 or 1 (800) 692-2326 (TTY) to request a hard-copy application from NPPES (the Enumerator).
  3. Permit an organization – known as an electronic file interchange organization (EFIO) – to obtain an NPI on his or her behalf through an electronic file interchange (EFI). Refer to www.cms.hhs.gov - National Provider Identifier (NPI) for more information about bulk enumeration.

 

 


How many NPIs may a healthcare provider obtain?


There are two types of healthcare providers in terms of NPIs:

  1. Type 1 - Healthcare providers who are  individuals , including physicians, dentists and all sole proprietors. An individual is eligible for only one NPI. *
  2. Type 2  - Healthcare providers who are  organizations , including physician groups, hospitals, nursing homes and the corporation formed when an individual incorporates him- or herself. Further, organizations must determine if they have “subparts” that require their own NPIs for unique identification in HIPAA standard transactions. A subpart is a component of an organization that furnishes healthcare and is not itself a separate entity. Refer to www.cms.hhs.gov/MLNMattersArticles/downloads/SE0608.pdf for more information about subpart designation.

 

*Note: An individual healthcare provider who is incorporated may need to obtain an NPI for her- or himself (Type 1) and an NPI for his or her corporation or LLC (Type 2).

 

The NPI is intended to identify the provider throughout his or her career. Organization NPIs also are intended to be permanent except in rare situations (e.g., a healthcare provider does not wish to continue an association with a previously used NPI, a provider’s NPI has been used fraudulently, etc.).

 


By what date am I required to have an NPI?


The NPI implementation date is May 23, 2007. At that time, HIPAA covered healthcare providers  must transmit standard EDI transactions using NPI, and health plans and clearinghouses must be able to accept EDI transactions with NPI. Small health plans have until May 23, 2008, to comply.

 

Although the NPI implementation date is several months away, HMSA encourages providers to apply for their NPI  now . As more providers wait to get their NPI at a later date, it is anticipated the volume of applications NPPES (the Enumerator) receives will increase and the length of time it takes to process NPI requests also will increase. Providers who wait until the last minute may not have their NPIs in time to file claims on May 23, 2007.

 

Providers should also ensure that their software is able to accommodate the NPI. This may require contacting the vendor.

 


Do I need to share my NPI with HMSA?


Yes! It is essential for HMSA to have all provider NPIs as soon as possible to ensure HIPAA standard transactions process correctly by the implementation date.

HMSA has begun contacting providers to acquire NPI information. If you have not received a communication requesting your NPI or an HMSA representative has not contacted you to obtain your NPI, contact your Field Representative. If you need assistance contacting your representative, call 948-5190 on Oahu or 1 (800) 603-4672, ext. 5190 from the Neighbor Islands.

 


What if I receive more than one communication from HMSA requesting my NPI?


If you receive more than one request to provide your NPI to HMSA, do not assume it is an error. HMSA has organized the mailing into groups (e.g., providers who direct payment to themselves, providers who direct payments to groups or clinics, providers who have more than one specialty, etc.). Some providers fall into more than one of these groups; therefore, the provider may receive more than one communication.

If you receive multiple communications from HMSA, carefully review the message and submit the requested information. Do not assume you have received a duplicate communication.

 


Why has HMSA not yet contacted me for my NPI?


If you have not received a request to provide your NPI to HMSA, please contact your Field Representative. For assistance contacting your representative, call 948-5190 on Oahu or 1 (800) 603-4672, ext. 5190 from the Neighbor Islands.

 


What will HMSA do with my NPI?


HMSA will use provider NPIs to update its records and systems, which will enable HMSA to process EDI transactions by the implementation deadline: May 23, 2007. HMSA will collect, use and disclose NPI only in accordance with applicable laws and regulations.

 


When does HMSA want me to begin using my NPI?


As soon as possible. Please contact HMSA EDI Support at 948-6355 on Oahu or 1 (800) 377-4672 from the Neighbor Islands to arrange to use your NPI in electronic transactions. The NPI must be used in all HIPAA-standard electronic transactions no later than May 23, 2008.

 


Will I still need to use my HMSA provider identification number(s)?


The HMSA provider identification number is required on all hard copy claims. EDI transactions may contain both the NPI and the HMSA provider identification number until May 23, 2008. However, beginning May 23, 2008, all EDI transactions must contain only the NPI and cannot contain the HMSA provider identification number.

 


What if I use my NPI before HMSA has notified me to do so?


EDI claims submitted with the NPI in place of the HMSA provider identification number may encounter processing delays or errors if HMSA has not been made aware prior to submission. Please contact HMSA EDI Support as soon as possible at 948-6355 on Oahu or 1 (800) 377-4672 from the Neighbor Islands to arrange to use your NPI in electronic transactions.

 


What if I submit hard-copy claims?


Covered healthcare providers who file hard-copy claim forms (CMS 1500, UB-92, ADA) can obtain an NPI, although the NPI mandate applies only to HIPAA standard transactions (e.g., electronic claims). HMSA encourages all providers to obtain an NPI, whether they file hard-copy or electronic claims.

 

The CMS 1500 hard-copy claim form was updated to accommodate NPI and became available October 1, 2006. HMSA automated its acceptance of the updated CMS 1500 claim form effective January 1, 2007. Providers may submit CMS 1500 claims using the new version of the form.

 

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Radiology Management

Does HMSA's decision to transfer the precertification of advanced imaging scans to National Imaging Associates (NIA) represent a change in HMSA benefits?

Is precertification required for all radiological procedures?

Is precertification required for imaging performed in connection with emergency department visits or observation room confinements?

Who is responsible for obtaining precertification?

What kind of response time can the ordering physician expect for his/her precertification request?

What is the toll free number for the NIA Call Center?

What are NIA's Call Center hours of operation?

Should precertification take place before scheduling an appointment with the facility to perform the services?

What should I do if services are needed on a weekend or holiday?

What information does the ordering provider need to expedite a call to NIA?

Can NIA precertify more than one planned procedure in a single phone call?

Will NIA issue one precertification number to cover two separate tests performed on the same date of service for the same patient?

Will precertification be required when HMSA is not the patient's primary coverage?

What if my office staff forgets to call NIA and goes ahead to schedule an imaging procedure requiring precertification?

If two authorization numbers are associated with the patient encounter, which one should be printed on the claim?

Why does NIA ask for a date of service when I can't schedule the procedure until I receive precertification?

How long is the precertification number valid?

Can the rendering facility obtain precertification in the event an urgent test is needed?

If NIA denies precertification of an imaging study, does the ordering physician have the option to appeal the decision?

How are procedures that do not require NIA precertification handled?

Is there a way to bypass the NIA recorded announcement?

How can a facility access information on an approved precertification?

Are there clinical guidelines?

What about the privacy of member information?

What will happen if precertification was not requested?

What will happen if precertification is denied?

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Does HMSA's decision to transfer the precertification of advanced imaging scans to National Imaging Associates (NIA) represent a change in HMSA benefits?


No, HMSA benefits for radiology services have not changed. HMSA covers medically appropriate imaging services under all lines of business. This change, which was effective October 16, 2006, is simply an administrative change.

 


Is precertification required for all radiological procedures?


Effective January 1, 2009, precertification is required for all advanced imaging scans. Precertification requirements have been waived for MRI, MRA, CT, CTA and nuclear cardiology services for selected providers. All ordering physicians are required to precertify functional MRI, PET, CT colonography and CCTA scans (ordered by cardiologists only). 

 


Is precertification required for imaging performed in connection with emergency department visits or observation room confinements?


No. Precertification is required only for outpatient services. Services performed in connection with emergency department visits or observation room confinements, and services rendered on an inpatient basis, do not require precertification.

 


Who is responsible for obtaining precertification?


The ordering physician is responsible for obtaining precertification, but it is in the best interest of facilities to verify that this has been done.

 


What kind of response time can the ordering physician expect for his/her precertification request?


In general, if the caller has sufficient clinical information on hand, about 60 - 65 percent of precertification requests can be approved during the initial phone call. On average, phone calls to NIA take about five minutes to complete.

 

If approval is not given in the initial phone call, NIA will generally issue a determination within two business days. In certain cases, the review may take longer if additional clinical information is required to make a determination.

 


What is the toll free number for the NIA Call Center?


1 (866) 306-9729

 


What are NIA's Call Center hours of operation?


The Call Center is open from 6 a.m. to 6 p.m., weekdays, Hawaii time.

 


Should precertification take place before scheduling an appointment with the facility to perform the services?


Yes, the precertification process should be completed before the ordering physician schedules the patient for the procedure. Facilities are advised to schedule patients only when they have confirmed that precertification has been given.

 


What should I do if services are needed on a weekend or holiday?


In urgent, emergent situations, HMSA recommends that services be performed as ordered. However, the ordering physician should contact NIA for retroactive precertification on the following business day. Nonurgent outpatient procedures should be precertified in advance.

 


What information does the ordering provider need to expedite a call to NIA?


The caller will be asked for the following clinical information:

  • Patient history and diagnosis
  • Reason for the study
  • Results of previous imaging studies
  • History of medical or surgical treatment

 


Can NIA precertify more than one planned procedure in a single phone call?


Yes, a physician may call with multiple precertification requests. Many offices find it easiest to batch information about all the cases that must be precertified and call NIA once a day.

 


Will NIA issue one precertification number to cover two separate tests performed on the same date of service for the same patient?


No. Each test must have its own precertification number.

 


Will precertification be required when HMSA is not the patient's primary coverage?


Pre-certification is still required when another carrier is primary to HMSA, but pre-certification is not needed when Medicare is primary to HMSA. 

 


What if my office staff forgets to call NIA and goes ahead to schedule an imaging procedure requiring precertification?


It is important that office staff be trained about the precertification process. In some cases, the facility may remind them to call NIA before they will schedule the procedure. But if a facility does not verify that precertification was given and proceeds with one of the specified procedures, the claim for the service may be denied and the member may not be billed for denied charges for services that are not deemed to meet HMSA criteria for coverage.

 


If two authorization numbers are associated with the patient encounter, which one should be printed on the claim?


Either of the two numbers may be printed on the claim form. The precertification number that does not appear on the claim form will be captured internally within HMSA's claims processing system.

 


Why does NIA ask for a date of service when I can't schedule the procedure until I receive precertification?


At the end of the precertification process the NIA representative will ask for the name of the facility that will be performing the test and for an approximate date of service. The date of service does not need to be exact.

 


How long is the precertification number valid?


The precertification approval will allow for a window of 30 days, beginning with the date of determination, during which the service must be performed. If the service does not take place within the approved time frame, please call NIA to update the precertification.

 


Can the rendering facility obtain precertification in the event an urgent test is needed?


A facility can contact NIA to begin the process, and NIA will follow up with the ordering physician to complete the process.

 


If NIA denies precertification of an imaging study, does the ordering physician have the option to appeal the decision?


Yes, there is an appeal procedure that is explained in NIA denial letters. If NIA makes the decision to deny the request at the end of the telephone call and the physician does not agree with NIA's determination, the physician may appeal the decision at that time.

 


How are procedures that do not require NIA precertification handled?


These procedures will continue to be handled as they are today.

 


Is there a way to bypass the NIA recorded announcement?


Yes, you may press "1" to initiate a new request for precertification, or press "2" for the status of a case about which you previously called.

 


How can a facility access information on an approved precertification?


Precertifications can be viewed on at  www.RADMD.com. On the right side of the home page is a section where a facility may log on and check the status of a precertification. The facility may search based on the patient's HMSA number or, if known, by the precertification number.

 


Are there clinical guidelines?


Yes, clinical guidelines developed by NIA have been adapted to meet HMSA's needs. The guidelines and algorithms will be updated periodically based on information from the latest medical literature, specialty criteria sets and empirical data.

 


What about the privacy of member information?


NIA is fully certified to handle all of the protected health information (PHI) it receives. HMSA's Business Associate Agreement with NIA requires that it protect the privacy of HMSA member information.

 


What will happen if precertification was not requested?


If precertification was not sought or given prior to services being performed, claims will be subject to review. HMSA will seek additional information from the ordering physician and will review the claim based on the information provided. This process will cause claims payment delays.

 

In addition, if the information provided by the ordering physician does not meet criteria for coverage, benefits will be denied for both the technical and professional components of the study. Neither the facility nor the radiologist may bill the member for the denied services.

 


What will happen if precertification is denied?


If precertification is denied because the service is determined not to be medically indicated, payment will not be made. The rendering provider may not bill the member for the denied services, except in cases where the member has been informed of the precertification denial, has agreed to be financially responsible for the charges, and has signed an Agreement of Financial Responsibility - Medical form prior to services being performed.

 

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First Published:05/02/2006
Latest Revision:10/23/2017
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