In-network HMSA dental providers will file your dental claims for you. Out-of-network providers are not required to submit claims on your behalf, so if you seek care from an out-of-network dental provider, you will need to ask if they will help with claim submission; if they don’t, you will need to submit a claim in order to be reimbursed for any out-of-pocket expenses allowed by your plan.
In order to be reimbursed, you will need to complete a separate claim form for each covered member who received services from each provider. To ensure your claim is processed quickly:
You will also need to include a signed letter with your claim that includes:
An itemized statement of services from your dentist in English or a statement in a foreign language with an English translation on the provider’s stationery will also need to be submitted with your claim. The provider statement must include all of the following:
A claim that does not include a provider statement will be denied. Statements you prepare, payment receipts, receipt of payment notices, or balance-due notices will not be accepted.
NOTE: 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.
Once completed, send your claim to:
HMSA Dental
P.O. Box 1320
Honolulu, HI 96807-1320
For individual Affordable Care Act (ACA) plans, HMSA allows a three-month grace period to pay each premium after the initial premium. The grace period for non-ACA Individual and group plans is 31 days. 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 will pay all eligible claims for services you receive during the first month of the grace period. We may hold claims for services rendered in the second and third months of the grace period if the member receives 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 canceled.
If the claim you submit includes all required information and documentation, we will send you an Explanation of Benefits (EOB) statement within 20 days (if a claim is filed electronically) and 40 days (if a paper claim is submitted) of receiving your claim. An EOB is not a bill; it’s a statement that explains how we processed a claim based on the services performed. It specifies the amount billed, the amount covered, the total paid by HMSA, any balance you’re responsible for paying the provider, and how much has been credited toward any required deductible or annual maximum.
If more information is needed or we are unable to make a decision due to unforeseen circumstances, we will extend our response time by 15 days. You will be notified within 30 days of the reason for the extension and when you can expect a decision. You’ll have at least 45 days to submit the required info or documentation if additional information is needed.
If any services on your claim are denied, the EOB will explain why. If you disagree with the decision to deny your claim or request for coverage and are unsatisfied with the explanation provided, you may request an appeal.
In certain circumstances, a claim may be denied even after you received a service and the claim has been paid. Examples of this include:
The best ways to prevent denials are to pay your plan premiums on time, confirm with your dentists what’s covered before you receive services, and review what’s covered in your HMSA dental plan before receiving care.
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 also responsible for billing the new insurance company for any covered services that you receive and were 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 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.
Prior authorization is an approval process to ensure that certain treatments, procedures, or devices meet payment determination criteria before the service is rendered. If you’re under the care of an in-network HMSA dental provider, they will obtain approval.
If your request for prior authorization isn’t urgent, HMSA will respond to your request within a reasonable time that’s appropriate to the clinical circumstances of your case, typically within 15 business days from the time your request was received. In the event of unforeseen circumstances, we may need to extend our response time by 15 additional business days. If this happens, we’ll let you know the reason for the extension and when you can expect a decision before the end of the first 15 business days. You’ll have at least 45 days to submit the required info or documentation if more information is needed.
Your care is urgent if delaying treatment could seriously risk your life or health or ability to regain maximum function or if your dentist or doctor believes that delaying care would result in severe pain that can’t be adequately managed without the care that was the subject of the request for prior authorization.
If you’re under the care of an in-network HMSA dental provider, they will obtain prior authorization for urgent dental care for you. HMSA will respond to your request for prior authorization of urgent care within 24 hours of receiving the required information.
If we don’t receive enough information to help us make a decision about the request, we’ll let you know within 24 hours. You’ll also be informed of what is needed and given at least 48 hours to provide it.
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.
