QUEST Integration – No-Fault

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

For vehicles with no-fault coverage purchased by the member, the no-fault carrier is the primary payer for claims resulting from illness or injury caused by the use, maintenance or operation of a motor vehicle. Submit claims to the responsible no-fault insurance carrier in accordance with Hawaii state law and regardless of fault.

Examples of situations covered by no-fault insurance:

• Injury caused by an automobile accident.
• Injury caused while opening or closing an automobile door.
• Injury caused while loading or unloading passengers or groceries from an automobile.
• Injury caused when children are playing in an unattended automobile.
• Injury caused by a hit-and-run automobile accident.
• Injury to a pedestrian involving an automobile.
• Injury to a bicyclist or moped driver involving an automobile.
• Injury caused by a person pushing an automobile.

Members who bought their own no-fault insurance and informed their Med-QUEST Caseworker about this coverage will have “Motor Vehicle Insurance” listed as a Third Party Liability (TPL) in their file. You can view active/applicable TPLs on HHIN. If your patient is involved in an automobile accident and has Motor Vehicle Insurance, please submit claims to the member’s no-fault insurance carrier first. If not indicated, but you are aware of available no-fault benefits, bill the no-fault carrier. Additionally, as a general reminder, patients should always be advised to report motor vehicle accident-related illnesses and injuries to their Med-QUEST Caseworker.

If the patient is injured while in a vehicle belonging to another person and that vehicle is insured by a standard no-fault plan, please bill the vehicle owner's no-fault carrier.

No-Fault Benefits Exhausted

When the patient exhausts no-fault benefits, the following documents must be submitted with a paper claim:

• A letter from the no-fault carrier indicating that no-fault benefits are exhausted
• A recap or summary from the no-fault carrier, indicating which claims were covered by no-fault

When received, HMSA’s Plan for QUEST Integration Members will process any remaining claims as the primary payer. Claims submitted after the filing deadline of 365 days from the date of service must be submitted for filing deadline waiver. See information in QUEST Integration – Claims Filing Tips.

Note: If the patient chooses to pursue further through the courts and receives a settlement, the Department of Human Services Med-QUEST Division will recover any moneys paid on behalf of the member for the accident. Such settlements may include funds to pay for ongoing care. In these cases QUEST Integration will no longer cover claims related to the accident. Claims will be denied as “Settlement Rec’d-Bill patient”. The patient should be billed for these services.

Hawaii Joint Underwriters Plan

Several no-fault carriers joined forces to create the Hawaii Joint Underwriters Plan for the Department of Human Services to provide no-fault coverage to public assistance recipients who meet the criteria for coverage. This no-fault plan does not include medical coverage; therefore, QUEST Integration is the primary payer for QUEST Integration patients injured in auto accidents involving vehicles insured with this no-fault coverage. Providers must check with the patient regarding the type of no-fault coverage. Please attach a copy of a rejection from the no-fault insurance carrier that indicates coverage provided through the state for public assistance recipients when submitting a claim to QUEST Integration.

Uninsured Vehicles

If the vehicle involved in the accident was not insured and there is no avenue to pursue no-fault benefits, HMSA’s QUEST Integration plan may be billed as the primary payer. Claims clearly must note that the vehicle was uninsured.

Recoupment of Payments

If payment is made for services that should have been billed to a responsible no-fault insurance carrier, HMSA’s Plan for QUEST Integration Members will recoup payments made to providers.

Revision History