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Filing Claims

HMSA participating providers and many nonparticipating providers will file claims for you. But if you see a nonparticipating provider who doesn’t file your claim, you’ll have to do it yourself.

How do I submit a claim?

Complete a separate claim form for each covered family member and each provider. You must file your claim within one year after the last day you received services; claims filed after one year aren’t eligible for payment.

Enclose a signed letter with your claim that includes the following:

  • A daytime phone number.
  • Your HMSA subscriber ID number.
  • Information about other coverage you may have.

Enclose an itemized provider statement from your dentist in English or a statement in a foreign language with an English translation on the provider’s stationery. The provider statement must include all of the following:

  • Provider’s full name and address.
  • Patient’s name.
  • Date(s) you received service(s).
  • Date of the injury or beginning of illness or injury.
  • The charge for each service in U.S. currency.
  • Description of each service.
  • Diagnosis or type of illness or injury.
  • Where you received the service (office, outpatient, hospital, etc.).

A claim without a provider statement will be denied. Statements that you prepare, cash register receipts, receipt of payment notices, or balance due notices are unacceptable.

Send your claim to HMSA Dental, P.O. Box 1187, Elk Grove Village, IL 60009-1187.

Payment of claims during grace period

HMSA allows a 31-day grace period to pay premiums. If subsequent premiums aren’t paid before the end of the grace period, the plan will end as of the 32nd day after the premium’s due date.

We’ll pay all eligible claims for services you receive during the first month of the grace period and may hold claims for services rendered in the second and third months of the grace period if the member is receiving Advance Premium Tax Credits (APTC) to pay a portion of the dental plan premium. If we don’t receive the premium before the end of the grace period, the plan will be cancelled.

Explanation of Benefits

An Explanation of Benefits (EOB) is a statement that explains how we processed a claim based on the services performed, the actual charge, and any adjustments to the actual charge, our eligible charge, the amount we paid, and the amount you may owe. A dental EOB is similar to a Report to Member that you may receive if you have an HMSA health plan.

Timeframe for claim determination

If we receive all the information we need to either approve or deny your claim, we’ll send you an EOB within 30 days of receiving your claim. However, if we need more information or are unable to make a decision due to circumstances beyond our control, we’ll extend our response time for 15 days. We’ll let you know within 30 days why we’re extending our response time and when you can expect our decision. If we need more information, you’ll have at least 45 days to provide it to us.

Denials

If any of the services on your claim are denied, the EOB will explain why. If you disagree with our decision to deny your claim or request for coverage, please call us for help. If you’re not satisfied with the information you receive and you’d like to pursue a claim for coverage, you may request an appeal.

There are certain cases when a claim for dental services 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 dental 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.

Retroactive claim denials

HMSA doesn’t request refunds for claims paid when a member’s termination date is adjusted retroactively unless the enrollee is ending their HMSA plan and enrolling in another insurer’s dental plan. In all other circumstances, once a termination date is placed in a member’s record, claims are processed or denied based on that date. However, if a member ends their HMSA plan and enrolls in another insurer’s plan, HMSA will request a refund from the provider for any claims paid after the retroactive termination date. The provider is responsible for refunding the member for payment of any cost shares. Providers are responsible for billing the new insurance company for any covered services that you receive and paid for after the retroactive enrollment date. HMSA instructs providers to collect only the copayment or coinsurance for the covered service to reflect the member’s cost-sharing obligation for their new plan. Such an adjustment may result in the member making additional payments to the provider. HMSA advises providers that any refund or credit for any excess cost sharing must be provided (or begin to be provided in the case of a credit) within 45 calendar days of the date of discovery of the excess cost sharing. In the case of premium paid for or on behalf of the enrollee, any refund or credit for any premium paid for or on behalf of the enrollee will be provided (or begin to be provided in the case of a credit) by HMSA within 45 calendar days of the date of discovery of the excess premium paid.

If you have questions about filing claims, call us at 808-948-6440 on Oahu or 1-800-792-4672 toll-free on the Neighbor Islands.

Prior Authorization

Prior authorization is an approval process to make sure that certain treatments, procedures, or devices meet payment determination criteria before the service is rendered. If you’re under the care of an HMSA participating dental provider or contracting provider, the provider will get approval for you.

Prior Authorization for Nonurgent Dental Care

If your request for prior authorization isn’t urgent, HMSA will respond to your request within a reasonable time that’s appropriate to the medical circumstances of your case. We’ll respond within 15 business days of receiving your request. We may extend our response time for an additional 15 business days if we can’t respond to within the first 15 business days and if it’s due to circumstances beyond our control. If this happens, we’ll let you know before the end of the first 15 business days. We’ll tell you why we’re extending our response time and when we expect to make a decision. If we need more information, we’ll let you know and give you at least 45 business days to provide it to us.

Prior Authorization for Urgent Dental Care

Your care is urgent if the time periods that apply to prior authorization for nonurgent care:

  • Could seriously risk your life or health or your ability to regain maximum function, or
  • In the opinion of your doctor or dentist, would subject you to severe pain that can’t be adequately managed without the care that’s the subject of the request for prior authorization.

HMSA will respond to your request for prior authorization of urgent care within 24 hours of receiving the information we need.

If we don’t receive enough information to help us make a decision about your request, we’ll let you know within 24 hours. We’ll let you know what we need and give you at least 48 hours to provide it to us.

You have the right to appeal

If you disagree with our decision, you may appeal.