Due to the wildfires on Maui, the provider requirements and/or services listed below have been suspended for all Maui County for services rendered through May 31, 2024. Prior Authorization requirements will be reinstated for services rendered effective June 1, 2024.
- Submission and processing of precertification requests, including post-acute discharge reviews, advanced imaging, pain management, outpatient rehab therapies, and chiropractic reviews through Evolent (fka Magellan Hawaii), behavioral health through Carelon (fka Beacon Health Options)
- Submission of PPO/HMO administrative review requests. Submission of QI out-of-network reviews.
- Submission of plan-directed care requests.
- Submission of faxed admission face sheets.
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Inpatient concurrent reviews.Submission of supportive care requests. For episodic care that will span 6/1/24, we encourage providers to request prior authorization to reduce possible claim processing issues.
Please proceedper best practice/standard of care guidelines and HMSA medical policies as published in the HMSA Provider Resource Center, which is accessible through hmsa.com or HHIN+ . HMSA reserves the right to review services on a retrospective basis and recover reimbursement if services rendered aren’t found to be medically necessary.
HMSA will continue to review out-of-state Air Ambulance requests.
In addition, HMSA will comply with any government standards or regulations that apply to access to care during a federal disaster or other public health emergency declaration.
For patients receiving physical medicine (physical therapy, occupational therapy, chiropractic) services during the waiver:
- For providers with approved authorizations via the waiver:
- If the validity period extends beyond 5/31/24 and no further care will be needed, there is nothing for the provider to do.
- If care will be needed beyond 6/1/24, a prior auth request will be required once the current auth validity period lapses. Additionally, for Evolent to perform a medical necessity review, provider will need to submit with the request the following:
- Initial evaluation
- Progress notes
- Daily notes
- Will any information regarding the completed/waived treatment need to be submitted?
- Providers do NOT need to upload anything into their auto approved authorization that was issued during the waiver period.
- For providers with approved authorizations via the waiver: