The Law
The Non-Discrimination in Health Care provision, section 2706 of the Public Health Service Act as added by the Affordable Care Act, expands the types of specialty services that health plans cover. As of January 1, 2014, complementary and alternative medicine (CAM) providers can submit claims on behalf of HMSA members for services that are:
- Covered by the member’s plan,
- Within the scope of their licensure/certification as defined by the Hawaii State Statute, and
- Medically necessary in accordance with Hawaii Revised Statutes (HRS) Section 432E-1.4.
Coverage will be based on the member’s existing plan benefits and all other terms of the member’s plan, including but not limited to medical and payment policy criteria.
Affected Plans
The provision applies to all plans that include the changes mandated by the Affordable Care Act for 2014. It doesn’t apply to Medicare Advantage, HMSA QUEST, grandfathered, or transitional plans.
Note: In November 2013, federal and state governments allowed members with small business and individual plans to keep their existing plans for 2014. These transitional plans don’t include the law’s new coverage requirements.
Checking Patient Eligibility and Coverage
To help you determine health plan benefits for preventive health services for your patients, we have compiled a list of plan coverage codes that have not implemented Affordable Care Act (ACA) requirements.
Check your patient’s HMSA membership card; the coverage code is listed under MEDICAL. If your patient has a chiropractic or American Specialty Health (ASH) rider, it’ll be listed under CHIRO or CMPCARE, respectively.
For all ACA Coverage codes visit HHIN+ to check the availability of benefits and applicable coverage levels.
Your patients’ plans and plan coverage may change throughout the year. Please check their eligibility and plan coverage at the time of their visit by calling Customer Relations at 808-948-6330 on Oahu or 1-800-790-4672 toll-free on the Neighbor Islands, Monday through Friday, 8 a.m. to 5 p.m.
State of Hawaii Provider’s Scope of Licensure
HMSA recognizes CAM providers as defined by Hawaii state law. Hawaii’s scope of licensure and/or certification criteria for CAM providers is at www.capitol.hawaii.gov/docs/HRS.htm. See HRS Section 442.1 (chiropractors), HRS Section 455-1 (naturopaths), and HRS Section 436E-2 (acupuncturists).
Note: CAM providers with a valid Drug Enforcement Administration number can prescribe medications.
Provider Participation Status
Eligible chiropractors can continue to enroll as HMSA participating or nonparticipating providers. Nonparticipating chiropractors can complete the HMSA New Provider Application to join HMSA’s participating provider network. At this time, no other CAM providers can become participating providers because we don’t have contracts with any other CAM providers. Newly eligible CAM providers, such as acupuncturists and naturopaths, can register as nonparticipating providers so that they can submit claims on behalf of HMSA members (see Registering as a Nonparticipating Provider).
Registering as a Nonparticipating Provider
We can’t process claims from providers who aren’t registered with HMSA. To register with HMSA, you will need to fill out the Provider Enrollment Form – Nonparticipating application form and include a copy of your current Hawaii State license, National Provider Identifier Confirmation, CMS Medicare Status letter, and W-9 form [PDF].
Examples of Services
Covered services that are defined in the CAM provider’s scope
- An office visit to a chiropractor for the diagnosis and/or treatment of a spinal injury would be covered because it’s within the scope of licensure for a chiropractor and a plan benefit.
Covered service that isn’t defined in the provider’s scope
- An office visit to a chiropractor for the diagnosis and/or treatment of an upper respiratory infection wouldn’t be covered because the scope of licensure for a chiropractor is limited to the treatment of the spine.
Non-covered services that are defined in the provider's scope
- An office visit to a naturopath is a covered benefit and within the scope of a naturopath’s practice. However, if the primary intent of the office visit is for services that aren’t covered by HMSA’s plans (e.g., cosmetic treatments that don’t restore or improve physical function), then we’ll deny the whole claim (including the office visit).
Filing Claims
Submit paper claims to HMSA using the CMS 1500 Claim Form. Or, file your claims electronically using HMSA’s e-Claim System [PDF] (participating providers only) or Electronic Data Interchange (EDI), which batches and sends us claims using your own practice management software.
- HMO members seeing nonparticipating CAM providers: We require an approved administrative review before a patient with an HMO plan can see a nonparticipating CAM provider. The HMO patient’s primary care provider or another physician in the patient’s health center must request the administrative review. We'll deny claims submitted by a nonparticipating provider for HMO patients without an administrative review.
- HMO members seeing participating HMSA providers: An administrative review isn’t required; however, your patients must get a referral from their primary care provider or another physician in their health center. When you file the CMS-1500 claim form, note the referring physician’s name in box 17.
- Note: We can’t process claims from providers who aren’t registered with HMSA (either as participating or nonparticipating providers).
More Information
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Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform. |