QUEST Integration – Payment for Noncovered Services

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Providers may collect fees from patients who request services that are not covered by the QUEST Integration plan. Members who self-refer to nonparticipating providers without their PCP referral, approved by HMSA’s QUEST Integration plan are also responsible for the services.

Patients also may be responsible for services rendered by participating providers if they self-refer to a specialist without going through the referral process with their PCP. Please refer to QUEST Integration – Referrals for services that can be patient self-referred such as women’s health specialists, family planning, etc..

If a provider will be billing a patient, the provider must inform the patient before services are rendered and the patient must agree in writing to the arrangements regarding the cost of the procedure and the payment terms. For provider convenience, a form sample is in the handbook (see Agreement of Financial Responsibility [PDF]).

Patients may not be billed if the provider fails to follow plan procedures resulting in denial of the services by QUEST Integration.

What Patients May Be Billed For

• Services that do not meet the payment determination requirements and services that are excluded from coverage as listed in QUEST Integration – Exclusions. The patient must have signed a financial responsibility statement agreeing to pay for the services before they were rendered.
• Upgraded services beyond what is covered under QUEST Integration, such as designer eyeglass frames. Members may be billed the difference between the charge for the upgraded service and the QUEST Integration allowance for the basic service provided the patient signed a financial responsibility statement agreeing to pay for the upgraded service before services are rendered. Available discounts should be applied.
• Services rendered while the patient was not a QUEST Integration patient; however, payments must be refunded to members who’s eligibility is reinstated to cover the prior service period. If the patient was confined in an acute facility when QUEST Integration coverage was terminated, QUEST Integration will cover inpatient services until the patient is discharged or the level of care drops below acute.
• Other insurance payments made by a primary insurer directly to the patient or the plan's subscriber.
• Services rendered by non-participating providers without prior approval by HMSA.
• Services when a member self-refers to a specialist without going through the referral process with their PCP, except for self-referral exceptions such as behavioral health services, women's health specialist, family planning, etc.. Please refer to QUEST Integration – Referrals for exceptions.

What Patients May Not Be Billed For

• Noncovered services that were not discussed with and agreed upon with the member in advance of services being rendered.
• Services that were denied because of the provider’s failure to meet claim or QUEST Integration requirements, including but not limited to the claims filing deadline, referral registration, precertification, and provider eligibility.

Revision History