HMSA Akamai Advantage® Select Plus (HMO) Referral Requirements

HMSA’s Akamai Advantage Select Plus HMO is designed to coordinate care through the member’s primary care provider (PCP) and the provider network.

HMSA Akamai Advantage Select Plus members are expected to receive medical services from their primary care provider (PCP) or another network provider whenever possible. Generally, a referral is needed when a member seeks non-emergent or non-urgent treatment outside of the plan network.

Using their professional judgment, providers should refer Select Plus members to other providers in the following order:

• To other providers within the MA HMO Network.
• To other HMSA participating providers.
• To providers and physicians participating in the Medicare program generally.

The requirements below apply when referring Select Plus members for services.

In-Network Services

If a service is ordered or referred by the member’s PCP or another in-network provider and performed by a different in-network provider, the servicing provider must identify the referring or ordering provider on the claim. Referred or ordered services include services such as specialist consultations, laboratory services, diagnostic imaging, anesthesia, therapy, and other diagnostic or treatment services.

For professional claims:

• Enter the referring or ordering provider’s name in Block 17 of the CMS-1500 claim form.**
• Include the referring or ordering provider information on electronic claims.
• Maintain documentation of the referral or order in the member’s medical record.

Including referral information on a claim does not replace prior authorization when the service itself requires prior authorization.

Out-of-Network Services

Services rendered to HMSA Akamai Advantage Select Plus members by providers who are not in the Network are not eligible for benefit coverage unless the member’s plan document allows for an exception (for example, in the case of emergency services) or HMSA has authorized the services through HMSA's administrative review process prior to services being rendered. Before referring an HMO member to an out of network provider, the member's PCP or other health center physician must submit a request for administrative review and receive HMSA's approval.

Submit the request through either:

• The HMSA provider portal, or
• The HMSA Precertification Request Form

The request must include:

• The HMSA Akamai Advantage Select Plus member’s information.
• The referring provider’s information.
• The proposed servicing provider and location.
• The requested service and applicable diagnosis and procedure codes.
• The reason an out-of-network provider is being requested, including why the service cannot reasonably be provided by network providers.
• Retroactive requests must be received by HMSA within 10 days from the start date of requested services.

Providers should not direct a member to an out-of-network provider until HMSA has approved the request for administrative review.

If Services Require Approval of Both Administrative Review and Clinical Prior Authorization

Some services require prior authorization regardless of whether the servicing provider is in or out of network. If the service to be provided by the requested out-of-network provider also appears on HMSA’s prior authorization list, the provider should submit one request containing the information needed for HMSA to conduct both:

1. Administrative Review of requested service(s) by an out-of-network provider.
2. Clinical review of the requested service(s) requiring prior authorization.

Approval of the service based on medical necessity does not, by itself, constitute approval of the use of an out-of-network provider. Both requirements must be satisfied when applicable. The submission process is the same as noted above.

Services That Do Not Require Referral

The following services do not require a referral:

• Services rendered by in-network providers, including but not limited to:
  • Most covered preventive services.
  • Routine women’s health care, including breast exams, screening mammograms (x-rays of the breast), Pap tests, and pelvic exams.
  • Preventive vaccines, including flu shots, COVID-19 vaccines, Hepatitis B vaccines, and pneumonia vaccines.
• Emergency care, including ambulance and outpatient claims related to an emergency room service.
• Services received after the plan authorizes a referral to an out-of-network provider.
• Urgent care, including services rendered at participating Urgent Care centers.
• Out-of-area dialysis, including kidney dialysis services from a Medicare-certified dialysis facility when a patient is temporarily outside of the plan’s service area.

*Providers are responsible for confirming the member’s eligibility, benefits, network requirements, and prior authorization requirements before providing non-emergent or non-urgent services. Obtaining a referral or prior authorization does not guarantee coverage or payment. Payment is subject to the member’s eligibility, benefits, applicable plan rules, HMSA Policies, and claim adjudication.

** Enter the referring or ordering provider’s information in the section titled Name of referring provider or other source (Item 17 & 17b of the CMS-1500 paper claim form or the 2310A Referring Provider Loop, segments NM101 using qualifier DN or DK, NM103-NM105 [Name], NM108 using [XX] qualifier, and NM109 [NPI] of the 837P electronic claim).

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