QUEST Integration – Eligibility

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

You may confirm a member’s eligibility by checking his or her current QUEST Integration membership card. The card provides you with several pieces of essential information including:

• The QUEST Integration member number.
• The name of the PCP and the effective date the member was assigned to the PCP.
• The type of coverage.
• Other insurance available to the member (TPL).

This member’s ID card should be adequate, in most cases, for you to file claims. However, there may be occasions when you wish to double-check eligibility for a specific patient. For example, you may wish to verify whether there has been a change in the PCP due to a member’s change of address. Other options for verifying eligibility:

• Subscribe to the Hawaii Healthcare Information Network (HHIN+). Through HHIN+, you may access our eligibility information electronically from your computer 24 hours a day, seven days a week.
• Call a QUEST Integration Provider Service representative at 808-948-6486 on Oahu Monday through Friday from 7:45 a.m. to 4:30 p.m. Neighbor Island providers may call toll-free at 1-800-440-0640.
• Call our after-hours toll-free number when you need immediate assistance with urgent or emergent cases requiring transportation arrangements, eligibility verification, or help locating a participating provider. The number is 1-855-874-8511. If your inquiry is not urgent, please contact a QUEST Integration Provider Service representative during regular business hours.
• Verify with the monthly PCP lists of eligible members. Each month, PCPs receive lists of eligible members assigned to them. At the beginning of each month, the Med-QUEST Division of the Department of Human Services sends us a list of that month’s eligible members. Within a few days of receiving this information, we send PCPs a list of changes to the previous month’s PCP list. At mid-month, a complete list of that month’s eligible members is sent to each PCP.

Note: Verification of eligibility does not guarantee payment. All services must comply with plan benefits and eligibility criteria in effect at the time of service.

New Eligible Members

New enrollees receive a Med-QUEST Integration confirmation letter as documentation of QUEST Integration eligibility until membership cards are received. The letter is valid for 30 days from the date of issue and gives the effective date of enrollment, the name of the QUEST Integration plan, and the eligible family members. After 30 days, new members should have received their HMSA membership cards.

Newborn eligibility is based on the mother’s eligibility on the date of the infant’s birth. Newborn services rendered within 30 days of the infant’s birth can be filed under the mother’s member number. Newborn drug claims billed with the mother’s number must be submitted on the universal claim form. Claims for services after 30 days must be filed with the infant’s own QUEST Integration membership number.

Note:Member eligibility is not guaranteed for each month. Therefore, treatment plans spanning more than one month should be carefully reviewed, and eligibility should be confirmed monthly.

Revision History