QUEST Integration – HMSA Organization and Administrative Structure

Original Effective Date:

07/01/2012

Current Effective Date:

01/01/2015

Organization and Administrative Structure

HMSA is an independent licensee of the national Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Association licenses HMSA to offer certain products and services under the Blue Cross and Blue Shield brand names. HMSA is an independent organization governed by its own board of directors and is solely responsible for its own debts and other obligations.

HMSA’s Plan for QUEST Integration Members is one of many health plans offered by HMSA. In partnership with the Department of Human Services (DHS), HMSA’s QUEST Integration plan covers eligible members as determined by the DHS Med-QUEST Department. Members who select HMSA as their QUEST Integration health plan are assured of a reliable plan with a large provider network, and supportive staff with the experience and background to help them get the care they need. Members can also participate in the many community and health plan activities offered by HMSA to its members.

HMSA is organized into many different business units that work collaboratively to deliver superior service to members and providers. Our Medicaid Programs Department is responsible for overseeing HMSA’s Medicaid activities and committed to ensuring HMSA’s QUEST Integration members and providers receive the best services available from HMSA while also tailoring those services when appropriate to meet the unique needs of our Medicaid population. Medicaid Programs provides support and oversight of the internal business areas responsible for administering all QUEST services related to contract requirements.

HMSA’s Internal Operations Department receives and processes QUEST Integration claims as well as manages enrollment for our members. They deliver timely and accurate processing to ensure members are loaded into our systems and providers are paid appropriately.

HMSA’s Finance and Accounting Department is responsible for financial reporting, payroll, and other financial services required to meet HMSA’s wide-ranging financial needs. They deliver comprehensive reports on payment, administrative expenses, and other pertinent financial information to help HMSA make informed decisions to promote maximum efficiency and effectiveness.

The Information Systems Department is responsible for strengthening HMSA’s ability to efficiently access and use business knowledge through continued improvement and innovation in information technology. The use of information and information technology is integral to most of HMSA’s products and services. The Information Systems Department is tasked with the leadership role for housing, deploying, and protecting information for systems and applications, and for the development of business solutions for HMSA.

HMSA’s Internal Audit department provides independent, objective assurance and consulting services designed to add value and improve HMSA’s operations. It helps HMSA accomplish its objectives by bringing a systematic, disciplined approach to evaluate and improve the effectiveness of risk management, control, and governance processes. They review and audit HMSA’s internal processes to identify and suggest opportunities for improvement, to ensure continued accuracy and excellence for all services delivered to HMSA’s members and providers.

The Medical Management Department helps to ensure HMSA’s members continue to receive quality care by administering plan benefits with sound medical policies and continually improving relationships with our health care partners. Key guiding principles include providing value to members, promoting evidence-based medicine, creating efficient and effective mechanisms between HMSA and providers to promote information sharing and mutually beneficial resolutions, and pursue innovation that is beneficial to members and providers.

The mission of the Member Advocacy and Appeals department is to positively support HMSA members through the process while ensuring compliance with all laws, regulations, contract requirements and providing service that is personal and transparent to cultivate loyalty and promote quality, affordable health care. The department’s activities contribute to HMSA's aspiration to enhance member and provider relationships with HMSA and to help HMSA deliver the best customer and provider experience possible.

HMSA’s Privacy Office provides strategic direction to meet privacy best practices and standards while ensuring compliance with all applicable laws, regulations, and requirements. The Privacy Office assists all HMSA business units by monitoring, maintaining, and enforcing the overall privacy stance of HMSA’s environment, ensuring privacy is considered and appropriately addressed in all of HMSA’s business processes, and providing business units with privacy guidance and advice.

Provider Services Department

HMSA’s Provider Services Department is responsible for caring for our health care delivery system, the providers who care for our members. Provider Services is responsible for all contracting activities with HMSA’s providers. Provider Services’ field representatives visit providers’ offices throughout the state to build rapport and help providers with contractual, administrative, and any other issues they need assistance with in regard to doing business with HMSA, and caring for HMSA members. This communication continues in statewide provider liaison committees and other provider advisory bodies through which Provider Services managers and medical directors meet with participating providers to exchange input on common health care issues. The department also coordinates provider communications, information and service through printed media (available to providers free of charge in both electronic and hard copy format) and supports a secured provider Intranet site, Hawaii Healthcare Information Network (HHIN+) that provides access to HMSA eligibility and claims data. In addition, the department manages provider information databases used for claim processing, provider reimbursement programs, and servicing members and providers.

In direct support of QUEST Integration providers, HMSA has a dedicated unit to help with QUEST Integration inquiries. HMSA’s QUEST Integration Provider Service unit is committed to providing quality customer service whether by correspondence or through telephone contacts. Providers visiting our offices are also able to meet with a representative.

Representatives can help providers resolve claim billing issues, answer benefit questions, confirm eligibility, and resolve other administrative issues that providers may face. In addition, representatives may initiate an education call if a billing trend or practice by the provider is noted that is affecting the provider's ability to obtain payments quickly and accurately.

The HMSA QUEST Integration Provider Service Unit is available Monday through Friday between 7:45 a.m. and 4:30 p.m. For urgent cases, an after-hours line is also available to help with eligibility and service coordination that is needed after regular office hours.

Revision History