Health Centers
These two Health Centers are known as the delegated HMO health centers.
What is Hawaii Health Partners/Straub and Pacific Health Care? KA#000005703
This is required when an HMO member is referred to a non-participating provider.
What is an approved HMO Administrative Review? KA 000006048
HMO members OOC needing emergent care will go here to get treatment and present their HMSA card.
What is the nearest ER? KA 000007118
This person is responsible for all primary care services rendered to HMO members.
Who is the PCP? KA 000006253.
The name of the referring provider can be found in this block of the CMS 1500 claim form.
What is Block 17? KA 000009310
This Health Center does not allow retro PCP changes.
What is Castle Health Group? KA#000008127
This type of HMO health center allows the PCP/HC physician the authority to refer out-of-network.
What are non-delegated HMO health centers?
KA 000005703
HMO members have access to this provider network when they are OOS.
What is the BlueCard Participating provider network? (which includes BlueCard Preferred and Participating providers) KA 000005860.
A future date HMO PCP change can be done in this system.
What is QNXT+? KA 000011219
This is the applicable provider qualifier code used for referring providers on the CMS 1500 claim form. HMSA will reject the claim if the qualifier code is missing.
What is qualifier code DN? KA 000009310
These Health Centers are on the Island of Hawaii.
What is BH (Community Clinic of Hawaii), EH (East Hawaii IPA), FR (Hawaii Health Partners - Straub Clinic & Hospital), HP (Hawaii IPA), KG (West Hawaii Independent Physicians), NH (Five Mountain Health Group)? KA#000008114
In general, HMO members may self-refer to this person without a referral from their PCP.
What is any provider within their HMO health center? KA 000006048
This process is required for OOS and OOC non-emergent and non-urgent services to be payable.
What is the HMO administrative review process? KA 000007117 for OOS and KA 000007118 for OOC.
This person can request a PCP change for a minor subscriber.
Who is the minor’s parent or legal guardian? KA 000009678
This is the applicable provider qualifier code used for referring providers on the CMS 1500 claim form. HMSA will reject the claim if the qualifier code is missing.
What is qualifier code DN? KA 000009310
This is said on every HMO call that comes into the call center.
What is the HMO Disclaimer? Generally, all services must be arranged by the member's PCP or health center provider. KA#000008114
HMO referral panel providers agree to accept this for services rendered to HMO members.
What are the HMO discounted fees? KA 000006425.
This health center has a policy where they will NOT submit HMO Administration Review requests for OOC services for their members.
What is Hawaii Health Partners/Straub.
KA 000008133.
These are the four ways to identify providers who have chosen to be an HMO PCP.
What are using the provider information on SF, using the hmsa.com provider search, using the HMO provider directory, using QNXT to identify HMO PCPs? KA 000006263
If a non-participating provider has an approved Administrative Review, HMSA will use this amount as the eligible charge.
What is the actual charge? KA 000006246
These hospitals are associated with Pacific Health Care.
What is Kapiolani at Pali Momi, Kapiolani Medical Center for Women and Children, Kuakini Medical Center, Queens Medical Center, Rehabilitation Hospital of the Pacific, and Shriners Hospital? KA#000006249
These three types of services are considered HMO implied referral services.
What are diagnostic tests, laboratory services, and radiology services? KA 000006250 (review chart and Notes in KA)
This KA describes how OOC inpatient claims processing and payment process differs depending on whether the inpatient services were arranged through Blue Cross Blue Shield (BCBS) Global Core or NOT.
What is KA 000007102, Private Business (PB) Out-Of-Country (OOC) Claims Processing and Payment.
If a provider is assigned as a member’s PCP but the member did not make the assignment, we can use this system to check if the provider assigned themselves as the member’s PCP.
What is Coreo Analytics? KA 000016972
Claims for services referred by the member’s PCP/HC providers to out-of-network (OON) providers require the PCP/HC physician’s name in this section of the UB-04 claim form.
What is Other Provider form locator (FL 78-79)?
KA 000006266