01 Dec Why HMO Issues Happen: Understanding Approval, Benefit Denials, and Clinic Accessibility

When using your Health Maintenance Organization (HMO) provider, one of the last things you want is to experience
slow approvals or worse — denied benefits. Why do these issues occur? Here’s a quick explainer and how to avoid them.

Key Takeaways

• Slow approvals typically result from operational, medical, and administrative factors.
• iCare members can reduce approval delays by using the iCare Mobile App.
• Benefit denials often stem from eligibility, coverage rules, documentation issues, and policy limitations.
• iCare provides access to 2,000+ accredited hospitals and clinics and 50,000+ accredited doctors.

Why Do Slow Approvals Occur?

Slow approvals usually arise from a combination of operational, medical, and administrative checks. Before authorizing a request, HMOs verify whether the member is active and eligible, whether the procedure is covered under the plan, and whether limits, exclusions, or pre-authorization rules apply. Any discrepancy, such as mismatched member data or unclear coverage, may delay the process.

How to Avoid Slow Approvals and Get an LOA Approved at iCare

If you are enrolled in a corporate HMO plan, you may request a Letter of Authorization (LOA) through the iCare Mobile App or by emailing msc@icare.com.ph.

Please provide the following details:

• Patient name
• Facility name (clinic or hospital)
• Date of availment
• Doctor’s name

Why Are Some HMO Benefits Denied?

Benefit denials commonly occur due to eligibility issues, coverage limitations, documentation gaps, and medical necessity assessments.

Eligibility Issues

• Member not active or coverage expired
• Waiting period not completed

Coverage or Benefit Limit Issues

• Benefit not included in the plan
• Package or sub-limit exceeded
• Use of a non-accredited hospital or doctor
• Non-emergency use of emergency room services

Documentation and Administrative Issues

• Missing required documents
• Incorrect or incomplete diagnosis

Medical Necessity Denials

• Services not considered medically necessary
• Procedures requested for convenience rather than treatment
• Experimental or non-evidence-based treatments

Policy Limitations and Exclusions

• Maternity coverage (for standard plans)
• Cosmetic procedures
• Dental services beyond basic coverage
• Injuries from high-risk activities
• Self-inflicted injuries
• HIV/AIDS coverage (varies by plan)

Clinic Accessibility at iCare

Does your HMO provider offer sufficient access to accredited clinics and doctors, or do you encounter network limitations? iCare members benefit from access to over 2,000 accredited hospitals and clinics nationwide, supported by more than 50,000 accredited doctors and medical practitioners.

App Accessibility

To streamline healthcare access, iCare members can use the iCare Mobile App. The app allows users to view membership details, monitor benefit utilization, request LOAs, check plan coverage, submit reimbursement claims, and access a digital HMO card.

Additional features include wellness tracking tools, medicine reminders, and access to accredited facility information.

Core App Features

• Quick access to membership and benefit information
• Digital HMO card
• Facility locator
• Availment summaries
• LOA requests
• Reimbursement submissions
• Wellness tracking tools