Report to Provider

This sheet summarizes the features of HMSA’s Report to Provider. A segmented sample Report to Provider, Hawaii Medical Service Association - Report To Provider, is located in this section.

One important feature of the report is its horizontal (landscape) printing, which allows room for more information. The report also has several new and more informative sections and within each section new columns provide additional information. The highlights of these features are as follows:

Sections

The report consists of five sections and a message code key. Claims received by HMSA are shown in the applicable section, depending upon their disposition.

Approved

This section shows claims that were approved by HMSA and information about the benefits applied to each claim. Columns you will particularly want to note are:

• Member Owes: Shows the member’s copayment.
• Message Code: Gives you a numeric code corresponding to a message found on the message code page. This message explains, line by line, any additional information you may need to understand the processing of the claim.
• Type of Service: Indicates the procedure codes you billed on your claim, including any modifiers.

Another item you will want to note is the message line immediately following each individual claim. This claim level message will give you additional information about the benefits that have been applied.

Adjusted

Any adjustments to previously processed claims are shown in this section. These may include any deductions made due to an overpayment (Example with explanatory text [PDF]).

Denied

Denied claims are shown in this section, along with message codes explaining why benefits were not allowed (Example with explanatory text [PDF]).

Claims in process

Most claims received by HMSA, even if processing has not been completed, are shown. This section is of particular value to both you and HMSA because you will no longer need to call HMSA to see whether we received a claim. Claims in this section will continue to appear each week until they are either paid or denied. One type of claim, however, does not appear on this report. Claims that were previously processed by both Medicare and HMSA must be specially handled if they are to be reprocessed for additional payment. Such claims will not appear on your Report to Provider until they are paid (Example with explanatory text [PDF]).

Summary totals

Totals of approved, adjusted and denied claims are shown on this page. These totals are summarized, and the total amount of your check is listed (Example with explanatory text [PDF]).

Message codes

This page is the final page of your report. It contains explanations of all the message codes used throughout the report (Example with explanatory text [PDF]).

Note: Providers who do not participate with HMSA receive an abbreviated Report to Provider when claims are denied for services rendered to HMSA members. The report includes a denied page, a summary total page and a message code page.

Nonparticipating providers do not receive a Report to Provider for claims that are paid. Claims that are paid for services rendered by nonparticipating providers are paid directly to the HMSA member. Payment for such claims may not be assigned to the nonparticipating provider.

Revision History