Hawaii Medical Billing and Payer Rules

Timely Filing in Hawaii

Hawaii and the Federal No Surprises Act

CMS found in 2021 that Hawaii has no state law setting out-of-network rates, so federal IDR applies to insured plans in the state. We confirm the plan type before filing any dispute.

Major Payers

How Does Hawaii Medicaid Work for Billing?

Hawaii Medicaid is run by the Med-QUEST Division (MQD) of the Hawaii Department of Human Services. Most members are enrolled in a managed care plan, and the rest are paid directly by the state. Which one applies decides where you send the claim.

The Med-QUEST health plans page says Medicaid services are delivered through a managed care organization (MCO) or fee-for-service, and that in Hawaii most services go through MCOs. Under an MCO the state pays the plan a capitation fee per member, and the plan pays providers. Under fee-for-service the state pays providers directly.

Fee-for-Service Claims Go to the Fiscal Agent

The provider manual sends fee-for-service claims, adjustments and inquiries to the Medicaid fiscal agent. The chapter we could open is dated December 2015 and names the agent of that time, so we do not name a current vendor. Confirm the claims address and portal with Med-QUEST before you set up an account.

The chapter limits a CMS-1500 to 25 service lines and a UB-04 to 99, and requires a live ink signature on paper claims, including UB-04s. Section 4.2 says other insurance, including Medicare, is primary: bill it first and wait for payment or rejection before filing for Medicaid. If an electronic Medicare crossover has not shown on your remittance advice within 30 days, the manual encourages a paper claim.

What Is the Timely Filing Limit for Hawaii Medicaid?

Hawaii Medicaid fee-for-service claims must be submitted within 12 months of the date of service, according to section 4.3.5 of the Medicaid provider manual, Chapter 4, revised December 2015. That covers initial claims, resubmissions and additional payment requests sent to the fiscal agent.

That is the edition of the chapter cited here, and Med-QUEST's provider manual page still links it. Check the current limit with Med-QUEST before a claim nears the deadline.

Section 4.3.6 requires a waiver when you cannot submit in time. You need evidence that claims were previously filed within the 12 months. Delays from third party payments, a court order or an administrative hearing decision can also be considered. List the client, dates of service and claim record numbers, attach documentation, and attach Med-QUEST's approval letter to the claim. The manual adds that Medicaid will not reimburse late charges.

Managed care plans set their own claim windows in their provider manuals, so check each plan. Read the plan's manual before you assume the state's 12 months applies to a QUEST Integration claim.

Which QUEST Integration Health Plans Pay Hawaii Medicaid Claims?

The Med-QUEST health plans page names five managed care plans: AlohaCare, HMSA, Kaiser Permanente, 'Ohana Health Plan and UnitedHealthcare Community Plan. Each delivers medical benefits and long term services and supports. Match the member's card to this list before you bill.

Med-QUEST sets no single statewide provider appeal procedure on that page. It points to each plan's materials and says to contact the Medicaid Ombudsman Office for help with a grievance or appeal against a health plan. The Hawaii Insurance Division adds that QUEST providers can take concerns to the Med-QUEST Provider Hotline.

How Do You Enroll as a Hawaii Medicaid Provider?

Hawaii Medicaid providers enroll through HOKU, the Med-QUEST Division's web-based enrollment system, which Med-QUEST says launched on August 3, 2020 as an alternative to the paper application. Providers use it to enroll, update and change their information.

You create a HOKU username and password first and then log on. Med-QUEST's fee-for-service page still lists the paper application, DHS 1139, with attachment forms by provider type, including DHS 1139D for acute hospitals.

Group billers (provider type 01) must have a Type 2 organization NPI with taxonomy code 193200000X, multi-specialty group, when they enroll or register. Med-QUEST text cited here does not say whether each location needs its own enrollment, so ask Med-QUEST in writing before you open a site. Plan credentialing is separate.

Who Is the Medicare Contractor in Hawaii?

Noridian Healthcare Solutions is the Medicare Administrative Contractor (MAC) for Hawaii Part A and Part B claims, in Jurisdiction E (JE). CMS lists California, Hawaii, Nevada, American Samoa, Guam and the Northern Mariana Islands together under that contractor.

This is from the CMS MACs by state document, March 2023 version, the newest we could open. The same document lists Hawaii home health and hospice claims with National Government Services and durable medical equipment claims with Noridian in the DME D region.

Under 42 CFR 424.44(a)(1), for services on or after January 1, 2010, a Medicare claim must be filed no later than the close of the period ending 1 calendar year after the date of service. Extensions apply where CMS or a contractor finds an error or misrepresentation by an employee, a contractor or an agent of HHS caused the delay. This page does not describe Noridian's current claim status tools, so use its Jurisdiction E portal. See our Medicare payer guide.

What Is Hawaii's Prompt Payment Law for Health Insurers?

Hawaii Revised Statutes section 431:13-108 requires covered insurers to pay an uncontested claim within 30 calendar days of a paper claim or 15 calendar days of an electronic claim, unless a contract sets shorter times. Interest on late payment is 15 percent a year.

The statute applies to accident and health insurers issuing comprehensive medical plans, mutual benefit societies, dental service corporations and health maintenance organizations. It does not list self-funded employer plans.

Payment counts on the postmark date of a mailed payment or the date of an electronic transfer. Interest starts on the first calendar day after the 30-day or 15-day period for an uncontested claim. For a contested claim, it starts 30 or 15 days after the added information arrives if notice was timely, and on the first day after receipt if it was not. Interest of at least $2 on a delayed clean claim must be added automatically.

For recoupment, the insurer must send written notice at least 30 calendar days ahead, and you have 60 days after receipt to appeal. It may not start recoupment more than 18 months after the original payment, except for self-insured employer groups, national participating provider networks and Medicaid, Medicare, Medigap and other federally financed plans. Fraud or material misrepresentation extends the limit to 72 months.

Does Hawaii Have Its Own Surprise Billing Law?

CMS found in December 2021 that Hawaii has no All-Payer Model Agreement and identified no state law governing the out-of-network rate. For that reason the federal independent dispute resolution (IDR) process applies to insured group and individual coverage in Hawaii.

The finding is in a CMS letter of December 23, 2021 to the governor, the Insurance Commissioner and other state officials. No newer determination is cited here, and the letter is nearly five years old, so confirm with the Hawaii Insurance Division or the No Surprises Help Desk.

The letter says the state agencies told CMS they lack authority to enforce several No Surprises Act provisions, and that the Insurance Division wanted a collaborative enforcement agreement on one, section 2799A-5(a), for insurers. Without an agreement CMS performs those functions in Hawaii. CMS also found no Hawaii dispute process for self-pay patients, so the federal patient-provider process applies.

CMS's No Surprises Act and state laws Q&A (revised August 2023) says a state cannot enforce its protections against a self-insured group health plan unless the plan opted in. We confirm the plan type on every account. See our table of state surprise billing laws.

How Do You Dispute an Out-of-Network Underpayment in Hawaii?

Start federal open negotiation, then federal IDR if the claim is still unresolved. CMS's 2021 letter says federal IDR applies to items and services from nonparticipating providers and facilities in insured plans in Hawaii, and the clocks come from 45 CFR 149.510.

Under 45 CFR 149.510(b)(1), the open negotiation notice goes out within 30 business days beginning on the day the provider receives the initial payment or denial, and the 30-business-day negotiation period begins the day the notice is submitted. Under (b)(2), IDR is initiated during the 4-business-day period beginning on the first business day after open negotiation ends. The regulation treats the date the Secretary receives the notice as the initiation date.

Our out-of-network billing and IDR service runs this sequence, and our emergency medicine billing page covers the claim side.

Which Commercial Payers Matter Most in Hawaii?

The Hawaii Insurance Commissioner's 2025 annual report lists HMSA, Kaiser Foundation Health Plan Hawaii Region, University Health Alliance, HMAA and AlohaCare among Hawaii health carriers. HMSA, a mutual benefit society, reported the largest premiums written of the mutual benefit societies and HMOs in the report's health table.

The report, a summary of insurance business for 2024, also lists CHA HMO Inc., Devoted Health Plan of Hawaii and Humana Wisconsin Health Organization Insurance Corp. as HMOs. It reports 2024 health premiums written of $4,417,859,494 for the Hawaii Medical Service Association and $2,033,558,863 for Kaiser. Premiums written are not market share, and the report ranks no carrier by share.

This page cites no source for Medicare Advantage plan names, so it lists none. See our guides to Kaiser Permanente, Medicaid and Medicare Advantage.

What Else Affects Hawaii Billing Offices?

The Insurance Division handles complaints about plans it regulates, and it sends other complaints elsewhere. Its page says to speak with an investigator first at 1-844-808-DCCA (3222), weekdays 7:45 AM to 4:30 PM Hawaii Standard Time, then use the online form.

The page routes Medicare complaints to CMS, QUEST concerns to Med-QUEST, and self-funded employer plans to the employer or the Employee Benefit Security Administration at 1-866-444-3272. A plan issued in another state belongs with that state's commissioner.

The Commissioner's report says the Health Branch runs independent external reviews of managed care plan coverage decisions appealed by members under HRS chapter 432E, with 31 requests in fiscal year 2024 to 2025. That is a member process, not a provider payment dispute route. This page makes no claim about the Prepaid Health Care Act.

How We Handle Billing in Hawaii

For a Hawaii account we separate three clocks at intake: the Med-QUEST 12-month limit and its third party exceptions, Medicare's one calendar year, and each plan's contract. Claims go out within 24 hours of charge entry, and denials are worked within 48 hours.

We confirm the patient's plan on the date of service, because five QUEST plans and fee-for-service pay differently. For underpaid out-of-network claims we run open negotiation and federal IDR with deadline tracking. Book a call and we will review your Hawaii payer mix first.