Frequently Asked Questions: Payment

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

Mail:

HMSA

Provider Data Administration, KLCR-PDA

P.O. Box 860

Honolulu, HI  96808-0860

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):

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:
  • E-mail: E-mail a Microsoft Excel file to PS_PIU@HMSA.com
• 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 808-948-6330 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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