Out-of-network services are from doctors, hospitals, and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing. In cases like these, you will be responsible for paying for what your plan does not cover. Balance billing may be waived for emergency services received at an out-of-network facility.

Yes. Nonparticipating providers don’t have a contract with HMSA and can charge more than the eligible charge for their services, leaving you responsible for paying a copayment, anything over the eligible charge, and any deductibles. Learn more about why nonparticipating providers are costly.

The copayment for covered emergency services is the same as a participating provider copayment, plus you have to pay the difference between the actual charge and HMSA’s payment. Read your Guide to Benefits to learn more.

All participating and most nonparticipating providers in Hawaii will submit claims for you. If a nonparticipating provider in Hawaii or an out-of-state provider doesn’t submit your claim, you can submit it yourself.

Send us copies of the provider’s statement and supporting documents with your HMSA subscriber number. Please note that you must submit claims within one year from the last day you received services.

To submit a claim, follow these claims submission instructions and then mail your claim to the appropriate address. If you have questions about submitting claims, call 808-948-6280 or 1-800-648-3190 toll-free.

If you miss premium payments, you must pay your balance in full before your plan’s grace period ends to keep your plan. Grace periods vary depending on your plan and tax credits.

For most ACA plan members:

If you don’t pay your first premium within 20 days of the bill’s due date, your plan will be canceled. If you pay your first premium but miss other payments, the grace period is 30 days after the bill’s due date.

We’ll hold any claims submitted during the grace period. If you pay all missed premiums, these claims will be processed and paid normally. If you don’t pay all missed premiums during the grace period, your plan will be canceled, the claims will be denied, and you’ll have to pay for them.

Avoid missed premium payments by setting up automatic payments.

For ACA plan members with an Advance Premium Tax Credit (APTC):

If you miss a payment, the grace period is 90 days after the bill’s due date. Claims will be paid for covered services received during the first month of the grace period.

If premiums remain unpaid after the first month of the grace period, CMS typically expects that health plans will begin pending claims for services received during the next two months. However, HMSA will continue to receive claims during the three-month grace period to allow you to catch up on any late premium payments. If you don’t pay all missed premiums during the grace period, your plan will be canceled, subsequent claims received during the second and third month of the grace period will be denied, and your provider may balance bill you for them.

Avoid missed premium payments by setting up automatic payments.

There are certain cases when a claim for a service may be denied, even after you’ve received the service and the claim has been paid. Some examples include:

• Using an expired HMSA membership card to get services. If the provider doesn’t verify eligibility over the phone or electronically, the service may be denied when the claim is filed.
• Not getting preauthorization for a service that requires it.
• Getting a service that’s not a benefit of your plan.
• HMSA isn’t your primary health care plan.

The best ways to prevent denials are to pay your premiums on time, talk to your providers about what’s covered before you get services, and know your HMSA plan benefits.

Call 808-948-6140 or 1-800-782-4672 toll-free for help with any refunds.

Precertification (also known as preauthorization) is a special approval process that makes sure a certain treatment, procedure, or device meets payment determination criteria before you receive it. These criteria protect member safety, promote appropriate use of services, and help keep health care costs in check. Precertification is also used to evaluate the medical necessity of the service or supply. Since your Guide to Benefits is updated annually, the list of services that require precertification may change during the plan year.

Some HMSA participating providers request approval for you, but others may not. Call HMSA or your doctor to find out who should request approval. If you don’t get approval, your plan may not pay for the service or product. Please read your Guide to Benefits for a complete description of payment determination criteria and requirements under Hawaii law.

Doctors, specialists, and other health care providers outside of HMSA’s network are nonparticipating providers. If you don’t get approval before you receive services from a nonparticipating provider, benefits may be partially or entirely denied and you may have to pay more.

A decision on a request for precertification for medical services will typically be made within 72 hours of receiving the request for urgent cases. If your request isn’t urgent, we’ll respond within 15 days after receiving it. If we need more time to review it, we’ll let you know why we’re extending our review and when we expect to make a decision. If we need more information from you or your provider, we’ll give you at least 45 days to provide it.

Your formulary [PDF] lists the generic and brand-name prescription drugs that are covered under your drug plan. Find your plan’s drug formulary on hmsa.com. For more information, read your Guide to Benefits.

If your drug isn’t on your formulary, you may qualify for an exception if you have a condition that didn’t respond to formulary alternatives or if your doctor says you should stay on your current drug.

If this applies to you, work with your doctor to ask for an exception, which is called a coverage determination. If you need a quick response for health reasons, your doctor can make an expedited request. Learn how to make a coverage determination request.

If you feel we have denied the non-formulary request incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO’s decision. Please see the following questions below for additional information on how to request an external review and the review timeframe(s).

After we receive your doctor’s statement, you’ll receive a decision within 72 hours for standard requests and 24 hours for expedited requests.

To request an expedited review for an exigent circumstance, you, your doctor, or your authorized representative should note that the request is for an expedited review.

ACA Non-Formulary Exception Request External Review

Per 45 C.F.R. section 156.122(c)(3): You or your authorized representative (who could be your doctor) have the option to request that our denial of your non-formulary exception request be reviewed by an independent review organization. If you want to ask for this review, contact us at the phone number on the back of your membership ID card. You must specifically state that you are requesting an "external exception review" when you contact us. You will receive a letter that responds to your request and explains the independent review organization's decision within 72 hours (or, for expedited exception requests, 24 hours) after we receive your request for the external exception review.

The decision of the independent review organization will be final and binding on both you and HMSA. You will have no additional appeal rights. If your external exception review is granted, HMSA will cover the requested non-formulary drug for the duration of your prescription (including refills), or, for an expedited exception request, for the duration of the exigency.

After we receive and process a claim for services, you’ll get a statement called a Report to Member. This report shows how much we paid for services and the amount you’re responsible for. The report is an explanation of benefits and isn’t a bill.

Please take time to read your Report to Member and call us if you see any inaccuracies. Learn how to read your Report to Member.

If you have more than one health plan (for example, you have a plan from your employer and you’re a dependent on your spouse’s plan), HMSA will coordinate benefits for you. This means we’ll apply rules to determine which plan pays first and which pays second.

Let us know if you have other coverage such as group insurance, other group benefit plans, Medicare or other government benefits, or health care benefits in your automobile insurance.

Please complete a subscriber questionnaire if you or your dependents have more than one health plan. If your plan ends or changes, please call HMSA at 808-948-6111 or 1-800-776-4672.

Congratulations! Quitting tobacco is one of the hardest things to do, but it can have lasting health benefits.

Monthly rates or premiums are locked in for the rest of the benefit year. For individual members, your plan year is Jan. 1 to Dec. 31. If you recently quit smoking and have a tobacco surcharge in your monthly premium, you can report the change in your smoking status during annual open enrollment or mid-year if you qualify for a special enrollment period, whichever occurs first.

If you enrolled in a plan through HealthCare.gov, you can update your enrollment application and smoking status on the website. Your premium will be adjusted once HealthCare.gov provides us with your updated enrollment information.

If you enrolled in a plan through hmsa.com, you can update your enrollment application and smoking status by logging in to My Account on hmsa.com. If the change is made during open enrollment, the premium adjustment will start on Jan. 1. If the change is made during a mid-year special enrollment period, the adjustment will start on the effective date of the change.

Learn more about your dental plan benefits at hmsadental.com.