HMSA — the Hawaii Medical Service Association — is Hawaii’s Blue Cross Blue Shield licensee, a mutual benefit society that runs both a QUEST Integration Medicaid line and commercial plans. For ABA intake the line matters more than the carrier: a QUEST member’s ABA benefit is Med-QUEST’s (memo QI-2431, under 21), while a commercial member’s is the plan’s own, sitting on top of Luke’s Law — which for mutual benefit societies is the chapter 432 counterpart of HRS § 431:10A-133 (under 14, $25,000 a year for ABA). Establish the line before anything else.
HMSA says "precertification" where most payers say prior authorization. ABA therapy is on both its QUEST and commercial precertification lists. Its ABA medical policy (effective September 1, 2025) and code-level prior-authorization list moved in May 2026 to a policy transparency site that requires accepting HMSA’s terms of use before it opens, so we have not read them and this guide does not state HMSA’s code-level or clinical specifics.
An HMSA QUEST member gets the Med-QUEST ABA benefit administered by HMSA: under 21, ASD diagnosis per the memo, treatment prior-authorized in hours per week for up to 26 weeks, supervision at 1–2 hours per 10 RBT hours, Medicaid secondary to other coverage. HMSA added "Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder" to its QUEST precertification list on November 19, 2021. Requests go on the HMSA precertification form by fax to (808) 944-5611 or through HHIN+, and HMSA decides "within the timeliness standards established by the National Committee for Quality Assurance (NCQA)." For QUEST, the federal managed-care limit — 7 calendar days standard, 72 hours expedited — applies.[1][2][3][6][7][12]
An HMSA commercial member is governed by the plan document, Luke’s Law (if the plan is fully insured and the child is under 14) and HMSA’s commercial precertification list, which also names ABA. The HMSA QUEST member handbook (April 2026) says EPSDT autism services "include all medically necessary intensive behavioral therapy and applied behavioral analysis." Its ABA medical policy (effective 9/1/2025) sets the clinical criteria for both lines but could not be read here.[1][2][3][6][7][12]
Hawaii’s autism mandate is Luke’s Law, Act 235 of 2015. It added the same autism section three times — to the insurance code as HRS § 431:10A-133, to chapter 432 for mutual benefit societies (HMSA’s chapter), and, through HRS § 432D-23, to HMO contracts — so every state-regulated carrier in Hawaii carries it. The text is narrow by current standards. Policies issued or renewed after January 1, 2016 must cover the diagnosis and treatment of autism for "individuals under fourteen years of age," and applied behavior analysis "shall be subject to a maximum benefit of $25,000 per year for services for children ages thirteen and under." Payments for anything other than ABA do not count toward that cap, and cost-sharing may be "no less favorable" than for substantially all medical services.[8][9]
The statute also sets rules intake should know: treatment requests "shall include a treatment plan," and the carrier may review the plan and medical necessity at its discretion; treatment must be "prescribed or ordered" by a licensed physician, psychiatrist, psychologist, licensed clinical social worker or registered nurse practitioner; coverage excludes custodial care, services by family or household members, experimental treatment and "services provided outside of the State"; network autism providers must clear state and federal criminal background checks; and a child diagnosed under an older DSM edition "may be required to undergo repeat evaluation" when a new edition is published. Exempt: self-funded employer plans (not state-regulated insurance) and disability, accident-only, Medicare, Medicare supplement, student, dental-only and vision-only policies and policies of six months or less. Whether a $25,000 annual ABA dollar limit can still be applied to a given plan alongside federal parity rules is a plan-level question; the statute text itself has not been amended since 2015.[8][9]
Hawaii licenses behavior analysts under HRS chapter 465D, run by the Department of Commerce and Consumer Affairs. A license requires having passed the BCBA examination and maintaining active BACB status as a BCBA or BCBA-D (HRS § 465D-8). Section 465D-7 exempts, among others, BCaBAs practicing "under the direction of a licensed behavior analyst," RBTs who directly implement ABA "under the direction of a licensed behavior analyst or a licensed psychologist," licensed psychologists and their supervisees, and graduate students and people accruing BACB experience hours under a licensed behavior analyst. Luke’s Law then limits covered autism treatment to providers "licensed by a state licensure board," so the supervising analyst on a commercial claim needs the Hawaii license, not just BACB certification.[11][10][15][8]
Not yet read: HMSA’s ABA medical policy and its code-level prior-authorization list — both now at hmsa.policytransparency.com, which asks users to accept HMSA’s medical policy terms of use before it shows content, so we did not open them. So the following are unknown here: whether 97151 itself is precertified, HMSA’s clinical criteria and diagnostic-tool requirements, hour thresholds, telehealth rules, and whether behavioral health is handled in-house. Note for maintainers: pVerify spells this payer "Hawaii Medical Service Assoc (HMSA)" and the payer name matches that spelling on purpose; a separate "BCBS of Hawaii" row in that directory is not covered by this name.[4][5]
The questions that decide whether a family can start with Hawaii Medical Service Assoc (HMSA) - Blue Cross Blue Shield of Hawaii, and what they have to bring. Each maps onto something intake should ask on the first call.
Commercial: Luke’s Law covers treatment "prescribed or ordered" by a licensed physician, psychiatrist, psychologist, licensed clinical social worker or registered nurse practitioner, with a treatment plan required on each request. QUEST: the MQD memo lets plans require a PCP referral for the diagnostic evaluation. HMSA’s precertification request asks for "physician’s orders."[8][7][2]
QUEST line: under 21 (MQD memo). Commercial: Luke’s Law covers "individuals under fourteen years of age" on fully insured plans; a plan may cover older children, and self-funded plans set their own terms.[7][8]
Ask the plan: HMSA benefits verification — confirm line of business, funding type and the plan’s ABA age terms.
No recency window in the MQD memo or Luke’s Law. Luke’s Law lets a carrier require a repeat evaluation when a new DSM edition is published. HMSA’s own policy is unread.[7][8]
Blocked on: HMSA ABA medical policy at hmsa.policytransparency.com.
QUEST line: the MQD memo’s list (developmental-behavioral or developmental pediatrician, neurologist, pediatrician, psychiatrist, psychologist, other licensed ASD-expert practitioner). Commercial: not verified.[7]
Blocked on: HMSA ABA medical policy at hmsa.policytransparency.com.
QUEST line: HMSA decides "within the timeliness standards established by ... NCQA," and the federal managed-care limit applies — 7 calendar days standard (for rating periods from January 1, 2026; extendable by 14) and 72 hours expedited. Commercial group plans: 29 CFR 2560.503-1 through 45 CFR 147.136 — pre-service decisions "not later than 15 days," one 15-day extension, urgent within 72 hours. We found no Hawaii statute setting a shorter initial-decision deadline; HRS § 432E-5 sets internal appeals at 72 hours (expedited) and 60 days.[2][12][13][14][17]
Ask the plan: HMSA precertification unit (808) 948-6464 / 1-800-344-6122 — confirm line of business and the turnaround HMSA commits to.
QUEST line: Medicaid is secondary to all other insurance (MQD memo). Commercial: order is set by the plans’ COB provisions; we found no Hawaii rule fixing birthday-rule order, so ask. If the child also has QUEST, HMSA commercial pays first and QUEST last; get HMSA precertification even then. TRICARE pays after other coverage except Medicaid; CHAMPVA pays last.[7][18][19][20]
Ask the plan: HMSA benefits verification — record every other coverage and ask HMSA which plan is primary.
QUEST line: "evidence-based assessments," with VB-MAPP or ABLLS-R-type goal measurement (MQD memo). HMSA’s own instrument requirements are unread.[7]
Blocked on: HMSA ABA medical policy at hmsa.policytransparency.com.
Not verified for ABA. QUEST members fall under MQD’s telehealth memo QI-2527 (audio-video, modifier 95/GT/GQ); HMSA lists its telehealth billing guidance at prc.hmsa.com/s/article/Telehealth, which was not read for ABA codes.[16]
Blocked on: HMSA Provider Resource Center telehealth article, or HMSA Provider Services (808) 948-6820 — ask which ABA codes are payable via telehealth.
Coverage decides whether Hawaii Medical Service Assoc (HMSA) - Blue Cross Blue Shield of Hawaii pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
QUEST line: MQD memo — 1–2 hours of case supervision per 10 RBT hours, at least one direct, and direct supervision at least 5% of BCaBA and RBT hours. Commercial line: HMSA’s ABA medical policy sets it and could not be read; Hawaii law lets RBTs and BCaBAs practice only under a licensed behavior analyst’s direction.[7][10][4]
Blocked on: HMSA ABA medical policy (eff. 9/1/2025) at hmsa.policytransparency.com, or HMSA Provider Services (808) 948-6330.
QUEST line: the MQD memo allows 97153 and 97155 concurrently when both codes’ criteria are met and they carry different modifiers. Commercial: not verified.[7]
Blocked on: HMSA ABA medical policy / billing guidance at hmsa.policytransparency.com, or HMSA Provider Services (808) 948-6330.
QUEST line: no memo cap; hours are approved per week for up to 26 weeks. Commercial: Luke’s Law caps ABA at $25,000 a year for children 13 and under on fully insured plans; any HMSA hour or unit limits are in the unread policy.[7][8]
Blocked on: HMSA benefits verification on the member ID, plus HMSA’s ABA policy at hmsa.policytransparency.com.
QUEST line: clinic, home or community per the MQD memo, with school ABA provided by DOE under the IEP; not covered outside Hawaii. Commercial: Luke’s Law excludes "services provided outside of the State" and does not reduce any IEP or IFSP obligation. HMSA’s own setting rules are unread.[7][8]
Blocked on: HMSA ABA medical policy at hmsa.policytransparency.com.
QUEST line: payment goes to the licensed practitioner or employing agency, with HO/HN/HM credential modifiers (MQD memo). Commercial: Luke’s Law covers treatment only from an autism service provider "licensed by a state licensure board," and network providers must clear state and federal background checks. HMSA’s credentialing and billing-provider rules are unread.[7][8]
Blocked on: HMSA Provider Services (808) 948-6330, or HMSA’s ABA policy at hmsa.policytransparency.com.
Not verified. Neither HMSA precertification article sets session-note signature rules; HMSA’s ABA policy may.[2]
Blocked on: HMSA ABA medical policy at hmsa.policytransparency.com, or HMSA Provider Services (808) 948-6330.
On the QUEST line HMSA administers the Med-QUEST ABA benefit for members under 21 with ASD. On fully insured commercial plans Luke’s Law requires coverage for children under 14, with ABA capped at $25,000 a year for ages 13 and under. ABA therapy is on both HMSA precertification lists.
HMSA’s word for prior authorization. QUEST requests go by fax to (808) 944-5611 or through HHIN+; the precertification unit is at (808) 948-6464.
Yes — HMSA is Hawaii’s Blue Cross Blue Shield licensee.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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