QUEST Integration – Medicaid Provider Enrollment – DHS 1139

Original Effective Date:

01/01/2018

Current Effective Date:

01/01/2018

To improve fraud prevention, the state Medicaid agency, Department of Human Services Med-QUEST Division (MQD), is required to perform a comprehensive screening, credentialing, and enrollment for all Hawaii Medicaid providers.

To become or remain eligible for Medicaid reimbursement, providers must complete and submit to MQD the Medicaid Provider Application/Change Request Form, also called the DHS 1139, once every five years. Even providers who have an active HMSA QUEST Integration contract may have their future payments suspended or denied if they don’t submit the DHS 1139 to MQD.

MQD Contact Information and DHS 1139 form

The DHS 1139 form and instructions may downloaded from the MQD website at https://medquest.hawaii.gov/en/plans-providers/become-a-medicaid-provider.html.

To contact MQD, call 808-692-8099 on Oahu or email hcsbinquiries@dhs.hawaii.gov. Due to higher-than-usual inquiry volume, the staff may not respond immediately. It is recommended that you make your best effort to complete the 1139 application and mail it to:

Med-QUEST Division

Health Care Services Branch

Provider Enrollment

601 Kamokila Blvd., Room 506A

Kapolei, HI  96707

Upon receipt of your application, MQD will contact you if there are any issues with your application that they need you to address. We advise to save a copy so that if corrections need to be made later, you can make corrections to the saved copy without having

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