Non-Physician Appealing a Precertified Denial

If you are appealing an FEP or Medicare Advantage claim, please refer to Federal Employee Program (FEP) or Medicare Advantage Provider Appeals.

If you are appealing a QUEST claim, please refer to QUEST Integration - Provider Reconsiderations, Grievances, and Appeals Process.

For the purposes of this document, physician is defined as a medical doctor. For claims appeals submitted by a non-physician, refer to Form to Appeal a Claim Denial [PDF].

Provider Inquiries

If a precertification request is denied, Providers may request a further explanation of the clinical reasons for the denial by calling HMSA at 808-948-6464 (Oahu) or 1-800-344-6122 (Neighbor Islands) to speak to the medical director who made the determination.

Internal Appeals

Providers may also appeal HMSA's precertification determination. The appeal must be in writing (unless you are requesting an expedited appeal) and made within one year of the original decision.  Only the primary care physician or the treating physician has the authority to act as the member’s representative without a completed representative form.  To appeal a precertification denial, both you and the member must complete the CMS-1696 Appointment of Representative form and submit it with your appeal.

If the appeal pertains to a clinical issue, the Provider may request a review by an Independent Review Organization (IRO).

Standard Appeal

HMSA will respond to an appeal as expeditiously as the member's health requires, but no later than 30 calendar days from HMSA's receipt of the request.

The appeal must be in writing and must be submitted to HMSA at:

HMSA - Appeals Coordinator
HMSA Appeals Unit
P.O. Box 1958
Honolulu, HI 96805-1958

OR

Fax: (808) 952-7546

OR

Email: appeals@hmsa.com

Providers must complete and submit the Form to Appeal a Precertification Denial [PDF], or submit a written appeal request. The appeal request must be sent to the above address to be recognized as an appeal, and must include the following information:

• Patient's name
• HMSA member ID number
• Provider's name
• Provider's identification number
• Description of the facts related to the appeal request
• Why you believe HMSA's decision is in error
• Copy of HMSA's denial letter
• Any written comments, documents, clinical records and journal articles not considered in the precertification review.

The appeal request, case documentation and any additional information provided will be reviewed. Both the Provider and the member will be notified in writing of the final internal appeal decision.

Expedited Appeal

Providers may initiate an expedited review if the member's health, life or ability to regain maximum function may be seriously jeopardized by the length of time needed for a standard appeal, or the member would be subjected to severe pain that cannot be adequately managed without the care or treatment that is the subject at issue.

HMSA will respond to an expedited appeal within 72 hours of HMSA's receipt of the request. Please call the Appeals Unit at 948-5090 (Oahu) or 1 (800) 462-2085 (Neighbor Islands). The request may also be made in writing to the HMSA Appeals Unit address or fax number listed above.

The Provider will be notified by phone of the final internal appeal decision, followed by a letter.

Arbitration

If the Provider is dissatisfied with the internal appeal decision, the Provider must request arbitration.

Arbitration is available to Providers who have a Participating Provider Agreement with HMSA. Otherwise, please refer to the Member's Guide to Benefits

If a Provider is dissatisfied with the internal appeal decision and wishes to pursue the matter further, they may request an arbitration within 60 calendar days of the date of the decision. Arbitration is final and binding. Refer to Arbitration for more information.

Revision History