QUEST Integration – Payment of Services Rendered

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Fee for Service

Payments to fee-for-service providers are subject to the QUEST Integration fee schedule, which is revised periodically taking into consideration:

• The cost of medical and non-medical services in Hawaii over the previous year
• The relative difficulty of the service compared to similar services
• Changes in technology that may have affected the difficulty of the service
• Payment for the service under federal, state and other private insurance programs
• The effect of changes on HMSA’s QUEST Integration rates

Acceptance of Fee Schedule Rates

Participating providers must accept the fee schedule payment allowance for covered services. No payment may be collected from a QUEST Integration patient except for:

• Payment of noncovered services that a QUEST Integration patient requested and agreed in advance in writing to pay for as a private non-QUEST Integration patient
• Other insurance payments paid directly to the patient or the subscriber of the plan for services rendered by a provider

Payments from QUEST Integration Patients

QUEST Integration patients are not required to make additional payments for covered benefits except as noted above. A hospital that accepts a QUEST Integration patient for treatment must make sure that the patient receives all medically necessary services, including those provided by medical staff. Hospitals must have in place an effective hospital-wide Quality Assurance program to evaluate patient care, including services furnished by a contractor; and take remedial action where deficiencies are identified. If a physician does not accept a particular patient for treatment or refuses to provide a covered service unless a patient makes a cash payment, the hospital is responsible for ensuring delivery of the service.

Coordination of Benefits with a Primary Coverage

When another insurance pays, QUEST Integration will pay the fee schedule allowance less the amount of the other insurance payment. If the other insurance payment is greater than the QUEST Integration allowance, the provider is entitled to the higher other insurance payment, but no further QUEST Integration payment can be made. Refer to QUEST Integration – Third Party Liability – Coordination of Benefits.

Dispensing Physicians

Physicians who provide take-home drugs to their patients because no pharmacy is within five miles of his/her office are paid for the cost of the drug plus a pharmaceutical dispensing fee equal to the fee paid to pharmacies. These physicians must submit drug claims via the CVS point-of-sale system or using the national drug claim form.

Physicians who dispense take-home drugs when a pharmacy is within five miles of the office are paid for the cost of the drug plus a physician-dispensing fee. These drugs may be billed on the CMS 1500 claim form.

Capitated Providers

Capitated providers are reimbursed on a per-month basis subject to the terms and conditions agreed upon in the provider participation agreement.

Revision History