Filing medical claims for services from nonparticipating providers
All participating and most nonparticipating providers in Hawaii will file claims for you. If your nonparticipating provider in Hawaii or an out-of-state provider does not file for you, you can submit a claim to us for payment. There is no form for you to fill out. Just send HMSA the statement prepared by your nonparticipating or out-of-state provider and make sure the statement includes all of the information listed below.
For timely claims processing, please submit your claim within 90 days from the last day on which you received services. Submit the claim to HMSA at the appropriate address.
Note: For information on Medicare claims, please refer to the articles 65C Plus (Cost) Evidence of Coverage, Senior Connection Plan Certificate or Akamai Advantage Evidence of Coverage.
What information you must file
Please send clear, legible copies of documents with your HMSA subscriber number written on each page. Keep the original for your records. Claim documents provided to HMSA will not be returned.
Your claim for services or supplies must include:
- A provider statement for the services or supplies.
- Your HMSA subscriber number.
- Your day-time phone number and address.
- Your signature.
Claims are only eligible for benefits with a provider statement. The provider statement must include all of the information below:
- Provider's full name, phone number, and address.
- Your name and birth date.
- Date(s) you received services.
- Date(s) of the injury or start of illness.
- The charge for each service. Cost for services that are listed in a foreign currency will be converted to U.S. currency at the exchange rate on the date of service.
- Description of each service.
- Diagnosis or type of illness or injury.
- Where the service was received (for example, an office, outpatient clinic, or hospital).
- Information about other health coverage you may have.
Note: Claims must be received within a year from the last day on which services were received. For HMSA's Plan for Federal Employees, claims will be accepted until Dec. 31 of the year after the year service was received. Refer to the Federal plan brochure for more information.
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