CurrentHawaii Medical Service Association (HMSA)Policy N/A

Complementary Care Rider — Acupuncture, Therapeutic Massage, and EngageFitness Program

Defines eligibility, covered services, limitations, exclusions, utilization review, claims filing, and member payment obligations for acupuncture services, therapeutic massage services, and the EngageFitness program as a rider supplementing HMSA medical plans.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyComplementary Care Rider — Acupuncture, Therapeutic Massage, and EngageFitness Program

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review Date

Key ActionSubmit utilization review (medical records) to ASH Group to request approval for more than five visits per calendar year.

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

12Annual visit maximum (combined)

5Visits triggering utilization review

$20Participating provider copay per visit

50% up to $30Nonparticipating payment per visit

Coverage Summary

This Rider, administered by American Specialty Health Group (ASH Group) and ASH Fitness, supplements HMSA's medical plan and provides additional coverage that starts and ends on the same dates as your HMSA medical plan coverage. It defines covered complementary care services including licensed Acupuncture Services and Therapeutic Massage Services, and provides access to the EngageFitness program (fitness center memberships and Home Fitness Kits).

Covered service categories include: licensed Acupuncture Services for indicated musculoskeletal, nausea, and pain conditions; Therapeutic Massage Services for specified myofascial/musculoskeletal, functional disorders, pain syndromes, and lymphedema; and the EngageFitness program offering participating fitness center memberships, premium upgrade options, wearable/home fitness kit selection, and connected activity tools.

Member payment and eligibility notes: member coverage under this Rider matches HMSA medical plan dates; participating provider copay is $20 per visit and nonparticipating provider payment is 50% of billed charges up to $30 per visit. The Rider aggregates visits across service categories toward the annual visit maximum and follows HMSA Guide to Benefits provisions except where modified by this Rider.

Coverage Criteria and Eligibility

General Eligibility

Coverage under this Rider supplements the medical plan and aligns with medical plan dates:

ALL of the following

Member must be covered under HMSA medical plan; Rider coverage starts and ends on same dates as medical plan coverage
All definitions, provisions, limitations, exclusions, and conditions of HMSA's Guide to Benefits apply except as specifically modified in this Rider

Utilization Review Requirements

When utilization review is required and who is responsible:

Responsibilities

Participating Provider: Utilization review responsibilities are provider's; therapeutic massage requires review of medical records after the fifth visit per calendar yearAfter the fifth visit per calendar year
Provider submits review
Nonparticipating Provider / Member: Member is responsible for utilization review for services from nonparticipating providers, including review of medical records after the fifth visit per calendar year; five-visit waiver applies to nonparticipating providers who work in same office under same tax ID; without complete information services may not be approved for reimbursementAfter the fifth visit per calendar year
Five-visit waiver applies to same tax ID; incomplete info may prevent approval

Provider Actions & Billing / Documentation Requirements

Prior Authorization

Approval required for >5 visits/year

Eligibility for benefits for more than five visits per calendar year requires approval. Providers (for participating) or members (for nonparticipating) must submit a utilization review (medical records) to ASH Group to request coverage beyond the five-visit threshold.

Documentation Required

Medical records required for utilization review

When requesting utilization review, submit a Medical Records Cover Sheet or Clinical Information Summary Sheet and include the following required elements. Incomplete information may result in denial.

Medical Records Cover Sheet or Clinical Information Summary Sheet (one per patient)
Date(s) of service and what services should be reviewed
Patient age and gender
Chief complaint
Pain severity
Mechanism or onset
Pertinent physical exam findings (at minimum: inspection and palpation)
Provider National Provider Identifier (NPI)

Billing Rule

Claims submission for nonparticipating providers

For services from providers who do not file claims, submit a separate claim form for each provider with an attached itemized bill. Required itemized bill/claim fields include dates of service, diagnosis code, procedure code, billed charge per service, provider name/credentials and full address, provider tax ID (EIN or SSN), and provider NPI. Mail claims and bills to ASH Group at the P.O. Box provided.

Complete a separate claim form for each provider
Itemized dates of service
Diagnosis code
Procedure code
Billed charge per service
Provider name, credentials, and full address
Provider tax ID / EIN or SSN
Provider NPI
Attach the provider's itemized bill
Send to ASH Group P.O. Box 509077 (or ASH Group P.O. Box 509001 as specified for Claims Departments)

Denial Risk

Services may be denied if not medically necessary or incomplete

Services provided during the utilization review period will be reimbursed only if ASH Group determines they are medically necessary and approves them. Missing or incomplete required documentation for the review may result in services not being approved for reimbursement.

Billing Rule

Copayment and nonparticipating payment rules

Participating providers: $20 copayment per visit. Nonparticipating providers: ASH Group pays 50% of billed charges up to a maximum of $30 per visit; the member is responsible for the remainder.

Billing Rule

Benefit aggregation

Each office visit for acupuncture or therapeutic massage counts as one visit toward the annual Benefit Maximum. Visits aggregate across service categories (acupuncture and therapeutic massage) and across participating and nonparticipating providers toward the same 12-visit limit.

Background & Definitions

The ASH Group/ASH Fitness rider supplements HMSA's Guide to Benefits and provides complementary care benefits through American Specialty Health entities. It makes EngageFitness available to eligible members and their dependents age 16 and older, while ASH Group administers acupuncture and therapeutic massage benefits.

Covered complementary care services include licensed Acupuncture Services and Therapeutic Massage Services provided by appropriately licensed providers for specified indications (musculoskeletal and related disorders, nausea, pain, myofascial disorders, musculoskeletal functional disorders, pain syndromes, and lymphedema). Adjunctive modalities may be allowed when provided in support of acupuncture during the same Course of Treatment.

The EngageFitness program is part of this Rider and offers participating fitness center memberships (standard and premium options with possible monthly buy-up fees), Home Fitness Kits (one kit per benefit year), the EngageFitness Connected! tracking tool, and an annual member fee structure. EngageFitness benefits are not subject to the plan deductible and certain services/products and non-participating fitness providers are excluded.

Course of Treatment: A sequence or series of office visits directly related to a diagnosed disease state, illness, or injury and provided in conjunction with a defined clinical outcome.

Acupuncture Services: Services by a duly licensed Provider of Acupuncture Services involving insertion/removal of single-use needles and/or electrical stimulation (electroacupuncture) to treat Musculoskeletal and Related Disorders, Nausea, and Pain; may include adjunctive physiotherapy modalities when provided during the same Course of Treatment.

Therapeutic Massage Services: Services by a duly licensed or certified provider using manual techniques (compression, stroking, joint movement, friction, vibration, percussion) applied to musculoskeletal soft tissue for Myofascial/Musculoskeletal Disorders, Musculoskeletal Functional Disorders, Pain Syndromes, and/or lymphedema.

Participating Provider: A provider who has entered into an agreement with ASH Group to provide Covered Services to Members; a directory of participating providers is available at hmsa.com.

Nonparticipating Provider: A provider who has not entered into an agreement with ASH Group to provide Covered Services to Members.

procedure_code	Procedure code — specific CPT/HCPCS not listed in document; provider must include
diagnosis_code	Diagnosis code — specific ICD-10 not listed in document; provider must include
NPI	National Provider Identifier
tax_id	Provider tax ID / EIN or SSN

OpenPayer

Complementary Care Rider — Acupuncture, Therapeutic Massage, and EngageFitness Program

Coverage Summary

Coverage Criteria and Eligibility

Provider Actions & Billing / Documentation Requirements

Required Claim Elements

Background & Definitions

Revision History