QUEST Integration – Claims Filing Tips

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

To expedite processing, clear, accurate information is essential. The following claims filing considerations particularly are important.

• Ask your patient each time he/she visits if there has been a change in his/her medical coverage so that you can update your records.
• Verify the patient’s birth date on the membership card with the date in your records. If the date on the card is incorrect, the patient must contact the Med-QUEST Integration worker or HMSA’s QUEST Integration Member Services to update the files. Claims submitted with a date that differs from the date in the state’s eligibility file will be delayed.
• We need the correct HMSA QUEST Integration provider number to process a claim. The claim will be returned if missing.
• Use the ICD-10-CM diagnosis code to indicate why specific services were rendered. If missing, the claim is delayed while the information is obtained. Always use the most current code book and select the most specific diagnosis available—through the fifth position only when appropriate.
  • Note: Do not add zeros after the decimal point to artificially create five positions.
• For accident claims, please check the type of accident and provide an accident diagnosis in the 800-999 range of ICD-9-CM diagnosis codes.
• Verify that the procedure and diagnosis codes are from the most recent version of the coding books. A simple transposition error can delay processing or result in incorrect processing. On the CMS 1500, the diagnosis in Column 24E should be the condition being treated by the procedure code in Column 24D. If they do not correspond, payment may be delayed while clarification is obtained.
• If you are a specialty provider, provide the name of the referring PCP (in last name, first name, middle initial format). Do not include the provider’s title (e.g., M.D.). Referring physician is required on claims for consultations, laboratory services, radiology services, podiatry and rehabilitative services.
• If you have more than one location or line of business, verify that you are using the correct provider number and that the number is active for the dates of service being billed.
• Be sure to accurately calculate claim totals.
• Fees charged must be according to the conditions outlined in HMSA's QUEST Integration Medical Service Agreement, including its Exhibits and Attachments.

Prompt Claims Filing

Please file claims timely. Claims not filed within one year from the date of service will be denied.

Filing Deadline Waivers

Only cases involving delays relating to a primary insurance coverage, or retroactive enrollment by Med-QUEST Integration will be considered for a filing deadline waiver. Include a copy of the claim, a reason for the late filing, and a breakdown of the dates and follow-up activities undertaken to resolve the billing. Copies of any other documentation related to the case that contributed to the late filing also should be provided.

Send requests to QUEST Integration Provider Service at:

HMSA – QUEST Integration Operations

Attn: Research & Correspondence

P.O. Box 3520

Honolulu, HI  96811-3520

Revision History