Original Effective Date:
12/01/2010
Current Effective Date:
06/01/2015
The HMSA QUEST Integration Provider Handbook is available online from the HMSA Provider Resource Center provider portal at https://prc.hmsa.com/s/. The handbook, which can be viewed by any provider, contains information on QUEST Integration benefits, claims filing information, and other administrative requirements. A hardcopy of the online handbook can be requested at no cost by calling QUEST Integration Provider Service at 808-948-6486 (Oahu), or toll-free from the Neighbor Islands at 1-800-440-0640.
Table of Contents
| QUEST Integration – Adjustment Claims | 3 |
| QUEST Integration – Advance Directives | 5 |
| QUEST Integration – Alcohol and Substance Abuse Management | 10 |
| QUEST Integration – Behavioral Health Assistance, Standard Care | 11 |
| QUEST Integration – Benefit Information | 13 |
| QUEST Integration – Benefit Overpayment | 16 |
| QUEST Integration – Codes That Do Not Meet Payment Determination Criteria | 24 |
| QUEST Integration – Provider Grievances and Appeals Process | 41 |
| QUEST Integration – Continuity of Care | 48 |
| QUEST Integration – Cultural Competency Plan | 50 |
| QUEST Integration – Dental Procedures Covered Under QUEST Integration Medical Plan | 56 |
| QUEST Integration – Drug Utilization Review | 59 |
| QUEST Integration – Eligibility | 60 |
| QUEST Integration – Eligibility – Membership Cards | 62 |
| QUEST Integration – Emergency Fills | 64 |
| QUEST Integration – Emergent/Urgent Care | 65 |
| QUEST Integration – Enabling Services (Social and Support Services) | 67 |
| QUEST Integration – Exclusions | 70 |
| QUEST Integration – Facility Role in Providing Technical Services for Procedures Requiring Pre-certification | 73 |
| QUEST Integration – Fraud | 75 |
| QUEST Integration – Hawaii Healthcare Information Network (HHIN+) | 78 |
| QUEST Integration – Health Education | 79 |
| QUEST Integration – HMSA Organization and Administrative Structure | 80 |
| QUEST Integration – HMSA’s Business Association with NIA | 83 |
| QUEST Integration – Lock-In Members | 84 |
| QUEST Integration – Locum Tenens and Temporary Hires | 85 |
| QUEST Integration – Medical Necessity | 88 |
| QUEST Integration – Member Billings | 91 |
| QUEST Integration – Member Inquiry, Grievance and Appeal Process | 92 |
| QUEST Integration – Member Rights and Responsibilities | 104 |
| QUEST Integration – No-Fault | 109 |
| QUEST Integration – Payment Determination Criteria | 111 |
| QUEST Integration – Payment for Noncovered Services | 113 |
| QUEST Integration – Philosophy of Care | 115 |
| QUEST Integration – Physician Responsibility for Obtaining Precertification of Imaging Studies | 116 |
| QUEST Integration – Pre-certification Timeliness Standards | 118 |
| QUEST Integration – Privacy | 121 |
| QUEST Integration – Provider Credentialing | 124 |
| QUEST Integration – Provider Grievances and Appeals Process | 127 |
| QUEST Integration – Provider Handbook Availability and Updates | 134 |
| QUEST Integration – Provider Participation Requirements | 135 |
| QUEST Integration – Quality Improvement Program | 138 |
| QUEST Integration – Plan Changes | 141 |
| QUEST Integration – Referrals | 142 |
| QUEST Integration – Refunding HMSA | 146 |
| QUEST Integration – Remittance Advice (Report to Provider) | 148 |
| QUEST Integration – Request for Fee Schedule | 149 |
| QUEST Integration – Responsibilities of the Primary Care Provider (PCP) | 150 |
| QUEST Integration – Responsibilities of the Specialist | 155 |
| QUEST Integration – Service Coordination | 156 |
| QUEST Integration – Third Party Liability – Coordination of Benefits – QUEST Integration and Medicare | 161 |
| QUEST Integration – Third Party Liability – Coordination of Benefits – QUEST Integration and Other Health Insurance (Health Maintenance Organization) | 163 |
| QUEST Integration – Third Party Liability – Coordination of Benefits – QUEST Integration and Other Private Insurances (Fee-for-Service Plans) | 165 |
| QUEST Integration – Third Party Liability (TPL) | 167 |
| QUEST Integration – Updating Your Provider Record | 170 |
| QUEST Integration – Utilization Management | 171 |
| QUEST Integration – Veterans Administration | 174 |
| QUEST Integration – Workers’ Compensation | 175 |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |