Travel Assistance Request Form The referring physician should fill out sections B C Please fax completed form to 808 944-5600 Or Mail to HMSA / Medical Management Dept. P. O. Box 2001 Honolulu Hawaii 96805-2001 Phone No 808 948-6464 Oahu 800 344-6122 Neighbor Islands HSTA Travel Reimbursement Benefit Airfare Reimbursement Taxi Reimbursement Parent/Guardian for a minor CONTACT INFORMATION Any questions or concerns regarding this request may be dir.
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How to fill out the Hmsa Travel Reimbursement online
This guide provides detailed instructions on how to complete the Hmsa Travel Reimbursement form online. By following these steps, you will ensure that your travel expenses are submitted accurately and efficiently.
Follow the steps to complete your Hmsa Travel Reimbursement online.
- Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
- Fill out section A: Member Information. Enter your membership number, patient’s name (last, first, middle initial), companion’s name (if applicable), date of birth, and specify the relationship of the companion.
- Proceed to section B: ICD-9-CM Diagnosis Code. Enter the appropriate diagnosis code(s) relevant to the patient's condition.
- Complete section C: Procedure/Service/Treatment Information. Provide the CPT/HCPCS code(s), along with the date of the appointment.
- Move to section D: Provider Information. Enter the requesting provider's name, provider ID, address, phone number, and fax number. Also, fill out the servicing provider’s details.
- In section E: Reason for Referral to Off-Island Provider, state the reason the requested service is not available on-island.
- Review all provided information for accuracy, and ensure completeness of the form.
- Once satisfied with the information entered, you can save changes, download, print, or share the form as needed.
Complete your Hmsa Travel Reimbursement form online today and submit promptly for reimbursement.
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Get answers to your most pressing questions about US Legal Forms API.
What is the phone number for HMSA claims?
Customer Service: Calls to these numbers are free: Current members may call 1 (800) 776-4672. Prospective members may call 1 (800) 618-4672.
How do I claim medical bills?
Submit the form and medical records to TPA. TPA will inspect all the documents. Once approved, the insurance company will settle the hospital bills, which excludes phone charges, attendant charges, food etc. In case of disapproval, one can file for reimbursement.
Does HMSA have financial assistance?
Financial and legal assistance Sometimes employees need financial or legal help and HMSA is standing by, ready to help. By providing debt consolidation and credit counseling, we help employees get back on track, giving them sound advice and hope for a more secure financial future.
What is reimbursement claim?
Reimbursement Claim refers to the type of claim wherein an insured must pay for the medical costs and treatment out of their pocket and later claim the bill from the insurance provider. For this kind of claim, the insured can visit any hospital for treatment and not necessarily the empanelled cashless hospital.
Can HMSA be used in other states?
HMSA members, except those covered by The HMSA Children's Plan, have benefits for medical services outside the U.S. through the BlueCard Worldwide network. All name changes must be submitted to HMSA as a signed request in writing with by documentation of the new name, such as a marriage certificate.
Does HMSA cover air ambulance?
Most HMSA plans include air ambulance benefits for emergencies in which transportation is needed to the nearest hospital within the state of Hawaii.
How do I request reimbursement from HMSA?
You can print the Prescription Reimbursement Claim Form from My Account on hmsa.com. You can also request copies by mail or in person. Use the Prescription Reimbursement Claim Form to request reimbursement for prescription drugs. Your dental claims information is accessible online through My Account on hmsa.com.
How do I apply for reimbursement?
Documents Required for Filing Reimbursement Claim Health Card Copy. Duly Filled Claim Form. Original Hospital Discharge Summary. Investigation Reports like scans, X-rays, blood reports, etc. Cash Receipts from Hospitals. If an accident happens, then FIR or medico-legal certificate(MLC)
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