HMSA Medical Policies, Formularies, and Related Information

You have entered the HMSA Provider Resource Center.

The material appearing in this section is specifically tailored to healthcare providers and their staffs. The documents described below include medical terms and other information that may be unfamiliar to some patients. As always, patients who have questions about their treatment should contact their healthcare providers.

Medical policies

Like other health plans in Hawaii and on the Mainland, HMSA develops detailed benefit-coverage guidelines regarding certain medical treatments and drugs. The guidelines are included in HMSA’s Medical Policies, which provide physicians with information they can use to determine when benefit coverage for a particular service is available for their patients.

Formularies

HMSA’s drug formularies are lists of medications that are covered under HMSA drug plans. Pharmacy and Formulary applies to most of our drug plans. Also see Formularies for HMSA’s Medicare Advantage Plans

Clinical information requirements

For certain healthcare services, HMSA asks physicians to submit clinical notes or surgery reports to help HMSA determine that the treatment meets benefit-coverage guidelines. These services are listed in Claim Documentation Requirements

Claims-filing procedures

Healthcare providers follow specific procedures when they submit claims to HMSA. The procedures are summarized in CMS 1500 Claim Form - General Instructions.

Overpayment procedure

HMSA occasionally pays providers too much for their services. When that happens, providers use the Reimbursing HMSA procedure to refund the overpaid amount to HMSA.

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