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 to happen is to face 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 usually come from a mix of operational, medical, and administrative factors
• iCare customers can avoid slow approvals by using the iCare Mobile App
• HMO benefits are usually denied because of eligibility, coverage rules, documentation issues, and policy limitations.
• iCare has a network of over 2,000 accredited hospitals and clinics and 50,000 accredited doctors

Why do slow approvals occur?

HMO issues like slow approvals usually come from a mix of operational, medical, and administrative factors. Before approving a request, HMOs need to confirm if the member is active and eligible, if the procedure is covered under the plan, and if there are limits, exclusions, or pre-authorization rules. Any discrepancy (e.g., mismatched member data, unclear coverage) slows down the process.

How to avoid slow approvals and get a Letter of Authorization (LOA) approved at iCare?

If you have a corporate HMO plan at iCare, you can request for an LOA at iCare Mobile App or email the following details to msc@icare.com.ph:

• Name of patient
• Name of facility (whether clinic or hospital)
• Date of availment
• Name of doctor

Why are some HMO benefits denied?

Benefits are usually denied because of the following: eligibility, coverage rules, documentation issues, and policy limitations.

• Eligibility
  • Member not active or coverage already expired
    If the premium wasn’t updated or the employer delayed remittance, claims can be rejected.
  • Waiting period not yet completed
    Some HMOs impose waiting periods for certain illnesses or for newly enrolled employees/dependents.
• Coverage or Benefit Limit Issues
  • Benefit not included in the plan
    Low-cost plans may not cover certain diagnostics, therapies, or specialist consults.
  • Package or sub-limit exceeded
  • Non-accredited hospital/doctor
    HMOs only cover accredited facilities unless it’s an emergency.
  • Non-emergency case used in ER
    If the reason for visit doesn’t meet the HMO’s emergency definition, it gets denied or classified as outpatient (with different rules).
• Documentation & Administrative Issues
  • Lack of required documents
    Missing: doctor’s order, compliance with LOA process, receipts, or medical abstracts.
  • Wrong or incomplete diagnosis
    If the attending physician enters a code or diagnosis that the HMO excludes, the claim may be rejected.
• Medical Necessity Denials

HMOs often deny services that they consider:

• Not medically necessary
  Example: requesting MRI when X-ray or CT is enough based on internal guidelines.
• For convenience, not treatment
  g., executive checkups, non-essential tests, over-utilization.
• Experimental or not evidence-based
  Some procedures, therapies, and medications are not covered because they aren’t part of standard treatment protocols.

• Policy Limitations and Exclusion

These depend on the plan but often include:

• Maternity (for regular HMO plans)
• Cosmetic procedures (e.g., acne surgery, warts removal)
• Dental beyond basic (if dental is even included)
• Injuries from dangerous sports
• Self-inflicted injuries
• HIV/AIDS (varies greatly by provider and plan tier)

How accessible are the clinics at iCare?

Does your HMO provider have a wide enough net of accredited clinics and doctors or are there inaccessible clinics? With iCare, you get access to over 2,000 accredited hospitals and clinics nationwide. The company also has an extensive network of more than 50,000 accredited doctors and medical practitioners across the Philippines.

App accessibility

To speed up the process of availing services, iCare customers can use the iCare Mobile app. It enables the user to access membership information to iCare, allowing the user to monitor their benefit consumption, request LOA, view the benefit plan coverage, request for a callback appointment, apply for reimbursement claim and use an on the go digital HMO card. The application is also equipped with helpful features designed to accommodate the user’s organization of medicine routine, timely recording of health status which includes tracking of glucose levels, cholesterol, blood pressure, weight, and creating notes on doctor’s appointments. It also provides trending health tips as well as information on accredited medical facilities. The app generally features the following:

• Quick Access Data References
  • All the important information about membership and plan benefit at the member’s fingertips, as well as access to digital HMO card.
  • Members can navigate or search for the nearest medical facilities
  • Members can check their availments summary and consumed benefit limit
• Interactive Transactions
  • Request for LOA, Request for Call Back, Reimbursement processing and Shared images capability of up to 5 image/photo uploads
• Wellness and Family Health Kit
  • Health Data Recording, Online Illness Inquiry, Medicine Reminders, Monitoring of Blood Glucose, Blood Pressure, Body Mass Index and Doctor’s Advice. iCare members can enjoy exclusive content about sleep with our new Sleep Better feature.