Setting Up Your Office to Bill HMSA and the Member

Basic Supplies You Will Need

There are certain basic supplies you will need to submit medical claims for HMSA members.

Reference books – current year

You will need a HCPCS book for looking up code related to DME items, supplies and injectable drugs. See Resource Books for more information. Resource books can also be purchased locally at:

R. Weinstein, 808-591-8331

JEL Enterprises, Inc. 808-678-8638

Vaccine codes are listed on the Immunizations page along with the appropriate diagnosis for the vaccines. If this list is used, you may not need to purchase a CPT book.

An ICD-9-CM code book would also be helpful for looking up diagnoses for injectable drugs and DME items when the member’s physician is not available to answer questions. A diagnosis code is always required on the CMS 1500 claim form. See CMS 1500 Claim Form - General Instructions, block 21. The physician should provide this information on the prescription for the injectable drug or DME item, but may not remember to do so, necessitating phone calls to the physician’s office.

CMS 1500 claim forms

If the pharmacy will be filing paper claims, CMS 1500 claim forms can be purchased from the local vendors listed in CMS 1500 Claim Form - Vendors.

The pharmacy may also choose to file claims electronically. For more information about electronic claims filing, call HMSA’s EDI Support Center at 808-948-6355 on Oahu or 1-800-377-4672 from the Neighbor Islands. If the pharmacy chooses to submit electronic claims using a clearing house or billing service, HMSA’s EDI Support staff with work with the clearing house directly to provide them with our technical specifications.

Electric typewriter or computerized billing system

Claims may either be typed or created using computer billing software. If you will be submitting paper claim forms, be sure to have a sufficient supply on hand of items such as typewriter ribbons, print cartridges and toner. It is important that you print the claim forms in black ink, using size 10 or larger font.

Setting Up Patient Records

It is important to get full information about the patient the first time he or she visits the pharmacy with a prescription for a vaccine, injectable drug or DME item that will be billed under the patient’s medical plan.

You should create a patient information sheet that includes the following information:

• Patient’s name (last, first, middle initial - no nicknames)
• Patients birth date and sex
• Patient’s HMSA number
• Patient’s relationship to the subscriber
• Name of the physician prescribing the item
• Subscriber’s name (last, first, middle initial - no nicknames
• If the patient is covered by a secondary insurance plan, include the name of the subscriber, the subscriber’s birthday, the name of the health plan and the member number of the plan.

You also should make a copy of the front and back of the member’s HMSA card which contains much of the information referenced above and can be helpful in verifying the information should discrepancies be discovered.

The patient information sheet, a copy of the member’s HMSA card, and a copy of the completed claim should be kept in the pharmacy’s file for future reference. If the patient is seen at a later date, ask whether there have been any changes in insurance coverage.

Tracking Claims and Billing Members

It is important to set up a record-keeping system that will allow you to track your claims, post HMSA payments, and bill the member for any remaining balance. This record-keeping can be done using either a paper log or a spreadsheet program.

A log should include columns that can be populated with the following information:

• Patient name
• Service date
• Date claim was sent to HMSA
• Date claim paid or denied
• Amount of HMSA payment*
• Amount of provider adjustment*
• Amount patient owes*
• Date bill sent to the member for any remaining balance
• Date member paid
• Comments

Other columns may be added as needed.

*This information is shown on the HMSA Report to Provider. Do not bill the member in excess of the amount shown in the Subscriber Owes column.

Revision History