Precertification - Medical

HMSA plans require that certain procedures be precertified. This document lists the services that require precertification and describes designated responsibilities in the precertification process.

Services that Require Precertification

Refer to Services That Require Precertification for a list of procedures and drugs requiring precertification.

Place of Treatment

In addition to the services that require precertification, the place of treatment may require precertification. For example, when a physician believes a procedure should be performed in a more acute setting than is normally deemed appropriate, precertification is required.

Refer to the Place of Treatment - Outpatient Procedures List and Place of Treatment - Office Procedures List for lists of procedures to be performed in office and outpatient settings.

Physician Responsibility

The physician is responsible for obtaining precertification. Refer to HMSA Precertification Request Form [PDF] for a general request. (Other precertification request forms can be found in the Forms Index.) Written requests should be faxed to 808-944-5611. Written requests may also be mailed to:

Benefit Precertification
HMSA - Medical Management Department
P.O. Box 2001
Honolulu, HI  96805-2001

Required components of a precertification request include, but are not limited to, the following:

• Brief history and physical/clinical notes
• Diagnosis
• Physician's orders
• Previous treatment
• Planned treatment (including photos and X-rays, if appropriate)
• Expected results
• Supporting information, if necessary

HMSA's Responsibility

HMSA’s Medical Management Department reviews precertification requests and provides the physician with a determination of benefit coverage within the timeliness standards established by the National Committee for Quality Assurance (NCQA). Please refer to Precertification Timeliness Standards.

If a precertification request is denied, physicians may request to discuss or clarify the decision with a physician reviewer by calling HMSA at 808-948-6464 (Oahu) or 1-800-344-6122 (Neighbor Islands), Monday through Friday, from 8 a.m. to 4 p.m., Hawaii Standard Time.

Facility Responsibility

The responsibility for obtaining precertification rests with the physician; however, the facility is responsible for confirming precertification at the time services are scheduled. If the necessary precertification is not obtained but the service is still performed, the facility may be held financially responsible for any unpaid services rendered by the facility.

The facility should first verify with the physician that precertification has been obtained from HMSA. If the physician indicates that precertification is pending, the facility may call HMSA prior to the service being rendered to determine if precertification has been granted.

HMSA's Precertification Unit can be reached at 808-948-6464 on Oahu or 1-800-344-6122 from the Neighbor Islands, from 8 a.m. to 4 p.m., Monday through Friday. You also may verify precertification by calling a Provider Services Teleservice Representative at 808-948-6330 on Oahu or 1-800-790-4672 from the Neighbor Islands.

Payment Implications

If the physician does not request precertification but the service is still rendered, the claim along with medical records may be reviewed for medical necessity. If services are determined not to meet payment determination criteria, HMSA will not pay for the services. The member may be billed for the noncovered charges only if the member signed a waiver accepting financial responsibility prior to the procedure. (The Acknowledgement of Financial Responsibility - Medical form may be used for this purpose.) Please ensure that HMSA members are fully apprised of their financial responsibility in this situation.

If a physician's request for precertification is denied, the member is responsible for the denied charges shown on the Report to Provider (RTP).

Revision History