What is Pacific Health Care?
Pacific Health Care (PHC) is a health center under the Health Maintenance Organization (HMO), Health Plan Hawaii (HPH), offered by the Hawaii Medical Services Association (HMSA). PMAG is the independent physician association that comprises the Pacific Health Care network of doctors. All PMAG physicians are participating providers within the Pacific Health Care network.
Out-of-Network Referral Management
Partners for Quality Health (PQH), a management services organization, continues to process PMAG’s out-of-network referral requests. PQH’s goal is to process referrals in a timely manner that will not compromise care for PHC members.
Updates to Pacific Health Care Out-of-Network Referral Management
A simplified version of the Out-of-Network Referral Request Form for PHC has been recently updated. Going forward, all out-of-network requests will need to be made using this form.
Please note the important updates:
- Allow a maximum of seven (7) business days to process requests
- Non-Urgent, Urgent, and STAT check boxes have been added to the form. Please specify clinically pertinent reasons before expediting any requests.
|For PHC Out-of-Network Referral Inquiries
Contact Referral Management
Phone: (808) 942-1852
For HMSA Member Inquiries
Contact HMSA Customer Relations
Phone: (808) 948-6372
For Out-of-State Provider Inquiries, HMO Administrative Review and Precertification Request
Contact HMSA Medical Management
Phone: (808) 948-6464
HMSA Provider Services
Phone: (808) 948-6330
Back To Top
Frequently Asked Questions
Why submit a Referral?
- Obtain authorization for a referral to an Out-of-Network (Non-PHC) provider within the State of Hawaii. Please note that out-of-state providers require a separate Administrative Review handled directly by HMSA.
- Claim re-processed for payment recovery without an approved referral form.
When to submit a Referral?
- Submit Referral form within 90 days prior to service date.
- Requested Information and/or documentation must be submitted to PQH within 7 business days.
Who submits a Referral?
- Preferably the member’s PCP will submit the referral. However, any PMAG physician may submit a referral on behalf of PHC members.
What form to use?
- Use ONLY the most updated Out-of-Network Referral Request Form (Revised 08/2016A).
When to go outside of the network?
- In-network specialties or services are not available within the Pacific Health Care network.
- There is a medical need to obtain services outside of the network.
How to submit?
- Fill out legibly and complete all required elements. Incomplete forms will not be processed.
- FAX to Partners for Quality Health at (808) 943-8732.
- Urgent and Stat requests require pertinent clinical reason.
Criteria for “NOT APPROVED” Requests:
- In-network provider is available to provide service or product.
- Monday through Friday from 9 a.m. to 5 p.m.
- Closed on most major holidays. However, fax transmissions can be received at all hours of the day at 943-8732.
Back To Top