Original Effective Date:
04/01/1999
Current Effective Date:
01/01/2015
The following services require precertification before being rendered.
Information on how to obtain precertification for most services can be viewed here, in the QUEST Integration – Precertification – Medical section of the Provider Handbook
If a claim was not yet submitted, providers can submit the HMSA Precertification request form and all supporting documentation to:
Benefit Precertification
HMSA – Medical Management Department
P.O. Box 2001
Honolulu, HI 96805-2001
Or
Fax: 808-944-5611
If a claim has already been submitted and denied for no precertification, providers will need to submit a corrected claim with all supporting documentation to:
QUEST Integration Claims
P.O. Box 3520
Honolulu, HI 96811-3520
Please note, there is no guarantee that retroactive requests will be authorized.
Written guidelines for most of these services are included in this handbook as referenced below.
Providers can obtain the UM criteria and hard copies of the criteria are made available to providers upon request by phone, fax, or mail to QUEST Integration Provider Service. The term precertification is the same as prior authorization.
- Advanced imaging studies, see the NIA website at RadMD.com
- Anesthesia Services for Gastrointestinal Endoscopic Procedures
- Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder
- Behavioral health services involving out-of-state services, out-of-network providers, transportation and lodging.
- Bone (Mineral) Density Studies
- Botulinum Toxins (BOTOX, DYSPORT, MYOBLOC and XEOMIN)
- Brachytherapy, Noncoronary
- Charged-Particle (Proton or Helium Ion) Radiation Therapy
- Clinical Trials – Routine Costs Associated
- Cognitive Rehabilitation and Sensory Integration Therapy
- Cosmetic surgery or surgery that may possibly be considered cosmetic.
- HMSA’s Plan for QUEST Integration Members does not cover cosmetic surgery primarily intended to improve a patient’s appearance without restoring or materially improving a physical function, nor surgery prescribed for psychological or psychiatric purposes. However, cosmetic surgeries that meet HMSA’s guidelines (see Cosmetic and Reconstructive Surgery and Services) and that appropriately documented are covered. Examples of services that may be considered cosmetic are:
- For a list of CPT procedure codes that may be considered cosmetic, see Cosmetic Procedures – Claim Documentation Requirements.
- To request precertification of cosmetic surgery, write to HMSA at the address listed for the Pre-Authorization Unit in the Quick Reference Guide.
- Glucose Monitoring of Interstitial Fluid
Drugs Requiring Prior Authorization
- See Pharmacy and Formulary
- In addition to non-formulary drugs, the following drugs also require prior authorization.
- Alimta (Pemetrexed)
- Avastin (Bevacizumab)
- CART-T (Kymriah, Yescarta, Zolgensma)
- Enbrel (etanercept)
- Erbitux (Cetuximab)
- Flolan (epoprostenol)
- Humira (adalimumab)
- Immune Globulin Therapy
- Lupron (Leuprolide Acetate) and Supprelin AL (Histrelin Acetate) Subcutaneous Implant
- Lutathera
- Off-Label Drug Use
- Remodulin (treprostinil)
- Specialty Drugs Requiring Pre-Certification [PDF]
- Spravato
- Stelara (ustekinumab)
- Synagis (Palivizumab)
- Teriparatide (Forteo)
- Vectibix (Panitumumab)
- Velcade (Bortezomib)
- Xolair (Omalizumab)
- Zevalin (Ibritumomab tiuxetan)
- In addition to non-formulary drugs, the following drugs also require prior authorization.
- Durable Medical Equipment, Prosthetics and Orthotics – Small Group & Individual Plans, Fed 87 and QUEST Integration [PDF]
- Genetic Testing for Hereditary Breast and/or Ovarian Cancer
- Genetic Testing for Lynch Syndrome/Colorectal Cancer and Polyposis Syndromes
- Genetic Testing for Non-Cancerous Inheritable Diseases
- Growth Hormone Therapy
- Hearing Aids
- Home Health Care
- Hospital admissions
- For elective inpatient surgery, it is expected the patient will be admitted on the day of the procedure. Requests for prior-day admissions will be reviewed to ensure the admission meets the payment determination requirements. Approval can be obtained by calling the HMSA Nurse Coordinator at 808-948-6464 on Oahu or toll-free at 1-800-344-6122 from the Neighbor Islands.
- Hospital beds (see Durable Medical Equipment)
- Insulin Pumps - External
- Intensity Modulated Radiation Therapy (IMRT)
- IV Therapies
- Albumin Therapy
- Home (IV) Hydration Therapy for Adults
- Home Total Parenteral Nutrition for Adults
- Intravenous Immune Globulin (IVIG)
- Long Term Support Services (LTSS) (requires patient assessment on the DHS Form 1147 and authorization of services by the Service Coordinator):
- Personal assistance services - Level I and Level II
- Personal emergency response systems (PERS)
- Residential care, including E-ARCH and CCFFH
- Environmental modifications
- Moving assistance
- Non-medical transportation
- Adult day care
- Assisted living services
- Community care management agency (CCMA) services
- Counseling and training
- Day health
- Home delivered meals
- Home maintenance
- Adult residential care
- Respite care
- Skilled (or private duty) nursing
- Specialized medical equipment and supplies
- Institutional services
- Acute waitlisted ICF/SNF (HMSA precertification not required; only the DHS 1147 form approval required)
- Nursing facility, skilled nursing facility, or intermediate care facility
- Subacute facility services
- RI/MRA/MRV (see Radiology Guidelines for Advanced Imaging Studies)
- Nutritional Therapy (see IV therapies)
- Occupational Therapy
- Organ Transplants and QUEST Integration – Organ Transplants – Donor Services
- High Frequency Chest Wall Oscillation Devices
- Transportation – Out-of-State
- Oxygen and Oxygen Equipment
- Panniculectomy/Abdominoplasty
- Photodynamic Therapy for the Treatment of Actinic Keratoses and Other Skin Lesions
- Physical Therapy
- Place of treatment exceptions for surgery
- A procedure that is normally done in an ASC requires precertification if it will be done in an inpatient setting. A procedure that is normally done in the physician office requires precertification if it will be done in an ASC, inpatient setting, or any other site other than the physician’s office. See the benefit policies section for the list of procedures that are normally done in the office or ASC setting.
- Polysomnography – Sleep Studies
- The guidelines for benefit coverage are noted in the benefit policies section.
- Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea
- Powered Mobility Devices
- Private Duty Nursing
- Risk-Reducing Mastectomy
- Pulse Oximeter for Children
- Reduction Mammaplasty
- Referrals to providers not in HMSA’s QUEST Integration network
- Referrals to providers who are not part of HMSA's QUEST Integration network must be approved. Refer to “Referrals” in the general information section.
- Remicade (Infliximab)
- Speech Therapy Services/Rehabilitation
- Spinal Cord and Dorsal Root Ganglion Stimulation
- Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy
- Supplies
- Surgery to correct morbid obesity (see Bariatric surgery)
- Surgeries, therapies or procedures employing new technology
- Surgeries, therapies, or procedures that meet payment determination criteria in accordance with HMSA’s guidelines may be considered with appropriate documentation.
- For a determination, please write HMSA’s Pre-Authorization Unit at the address listed in the Quick Reference Guide of this section.
- Surgical Treatment of Femoroacetabular Impingement
- Transportation, Ground (Non-Emergent) and Interisland Air Transportation
- Treatment of Varicose Veins
- Uterine Artery Embolization to Treat Fibroids
- Wheelchairs
Lupron (Leuprolide Acetate) and Supprelin AL (Histrelin Acetate) Subcutaneous Implant)
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |