The HMSA QUEST referral form that most people are looking for is the Community Integration Services (CIS) referral — a three-part fillable PDF used to connect a QUEST Integration member who is homeless or at risk of homelessness, and who has a qualifying health condition, with housing-related support services. You complete it, attach a signed consent and basic documentation of the member’s qualifying condition, and fax or email it to HMSA or to whichever QUEST Integration plan the member belongs to. Incomplete forms come back, and the member waits, so getting it right the first time is the whole game.
Who the Form Is For
CIS is a narrow track, not a general specialist referral. The member must meet two tests at the same time.1HMSA. Community Integration Services (CIS)
On the health side, they need at least one of the following: a serious mental illness; a substance use disorder assessed at ASAM level 2.1 or higher requiring outpatient day treatment; or a long-term or indefinite physical condition that needs improvement, stabilization, or prevention of further decline in daily functioning.
On the housing side, they must be currently homeless — lacking a fixed, regular, and adequate nighttime residence, which includes sleeping in a car, a park, an abandoned building, or a supervised shelter such as transitional housing — or at risk of homelessness, meaning they have written notice they will lose their residence within 21 days of the referral date and no next housing lined up.2Hawaii Department of Human Services. QUEST Integration CIS Referral Form
Members already enrolled in the Community Care Services (CCS) behavioral health program receive their housing and tenancy support through CCS, not through HMSA’s CIS track.1HMSA. Community Integration Services (CIS)
Who Can Submit It
This is not provider-only paperwork. The form’s first section lets the referrer identify as the member themselves, a family member or friend, a medical provider, a social or housing services agency, a correctional facility, another health plan, a nursing home, or an internal HMSA referral.2Hawaii Department of Human Services. QUEST Integration CIS Referral Form A shelter case manager who spots an untreated chronic condition in a client can start the referral without waiting on a physician.
Get the Form and the Consent
The fillable PDF lives in HMSA’s QUEST Integration Forms Index on the provider resource center. You can complete it on screen and print it to fax.3HMSA. QUEST Integration – Forms Index A signed consent form must travel with the referral; HMSA’s CIS page is explicit that both documents go in together.1HMSA. Community Integration Services (CIS) Pull the consent at the same time you pull the referral so you are not chasing a signature after the fact.
Filling Out the Three Parts
No clinical codes, no provider tax IDs, no insurance subscriber numbers. If you are used to precertification paperwork, strip that reflex out before you start.
Part 1: Referral Source
Check the box describing your relationship to the member. Add your name, your agency if you have one, a contact person for follow-up, the referral date, and your phone, fax, and email. HMSA’s CIS team uses this to reach you for clarification, so double-check the contact details before you send.
Part 2: Member Information
Fill in the member’s full name and middle initial, age and date of birth, HMIS number if they have one, Medicaid ID number, health plan (HMSA, AlohaCare, Kaiser, Ohana, or United), current location or address — including areas they frequent if they have no fixed address — and best contact phone and email.
The form also asks whether the member is a threat to themselves or others, whether they are in immediate danger or experiencing violence, and whether they need an interpreter. Answer these honestly rather than leaving them blank. They drive how fast the CIS team responds.2Hawaii Department of Human Services. QUEST Integration CIS Referral Form
Part 3: Presumptive Eligibility
This is the part that decides whether screening happens. Check at least one qualifying health need and at least one homelessness risk factor, and attach documentation that backs the health need. For mental health, attach a certification of severe and persistent mental illness or clinical documentation from a provider attesting to serious mental illness. For substance use, include the ASAM assessment. For complex physical health needs, attach records describing the condition and how it affects the member’s ability to live independently.2Hawaii Department of Human Services. QUEST Integration CIS Referral Form You do not need to send a full chart. The CIS team runs its own screening; the attachments just keep them from bouncing the referral back for basic proof.
Where to Send It
There is no online portal for this form. Fax or email only.
For HMSA members, fax the completed form and consent to 808-948-8243 or email them to HMOps-HCCIS@HMSA.com.1HMSA. Community Integration Services (CIS)
If the member is on a different QUEST Integration plan, fax the first page with “ATTN: QI CIS Program” on the cover sheet:
- AlohaCare: 808-973-0676
- Kaiser: 855-416-0995
- Ohana: 855-703-8078
- United: 866-314-3005
- CCS: 855-703-8078
- Med-QUEST (if you do not know the plan): 808-692-8087
If you are not sure which plan the member belongs to, send it to Med-QUEST and they will route it.2Hawaii Department of Human Services. QUEST Integration CIS Referral Form For urgent referrals, call the plan’s provider services line to confirm the fax arrived. A fax that disappears into a queue helps no one.
What Happens After You Submit
Federal Medicaid managed care rules set the clock. For rating periods beginning on or after January 1, 2026, a standard authorization decision must come within seven calendar days of the plan receiving the request, down from the earlier 14-day window.4eCFR. 42 CFR 438.210 The plan may extend by up to 14 additional days if the member or provider asks for more time, or if the plan needs more information and can show the extension benefits the member.
When a provider indicates that the standard timeframe could seriously jeopardize the member’s life, health, or ability to function, the plan must issue an expedited decision within 72 hours.4eCFR. 42 CFR 438.210 If you flagged the member as a threat to themselves or in immediate danger on the form, request expedited handling at the same time. HMSA notifies both the requester and the member of the decision in writing or by electronic alert.
If HMSA Denies the Referral
An adverse benefit determination — a denial, restriction, or reduction — must come with a notice explaining the reasons, the member’s right to appeal, how to file, how to request expedited review, and the member’s right to keep receiving benefits while the appeal is pending.5eCFR. 42 CFR 438.404 If any of that is missing from the notice, call HMSA provider services and ask for a complete one.
The member, an authorized representative, or the member’s doctor has 60 days from the adverse determination to file an appeal with HMSA. Appeals can be verbal or written and should include the member’s name, address, phone, HMSA membership number, the date, the facts supporting the appeal, and any related records. HMSA acknowledges receipt within five business days and decides within 30 calendar days, with a possible 14-day extension if HMSA notifies the member in writing explaining why. If the appeal decision still does not resolve things, the member has 120 days to request a state administrative hearing through the DHS Administrative Appeals Office.6HMSA. QUEST Integration Member Grievances and Appeals
When This Is the Wrong Form
The CIS referral is only for Community Integration Services tied to homelessness plus a qualifying health condition. For other QUEST Integration medical services — durable medical equipment, physical therapy, inpatient care, other clinical treatments — the correct path is HMSA’s precertification request, a separate form with clinical documentation requirements (brief history, diagnosis, physician’s orders, previous and planned treatment, expected results) that goes through the HHIN+ portal, by fax to 808-944-5611, or by mail to HMSA’s Medical Management Department at P.O. Box 2001, Honolulu, HI 96805-2001.7HMSA. QUEST Integration – Precertification – Medical Sending a CIS form when you need precertification, or the reverse, will delay care while the paperwork gets rerouted.
For questions about any part of the referral process, the Department of Human Services runs a QUEST Integration hotline at 808-692-8099 on Oahu.8HMSA. HMSA Directory – Provider Resources Med-QUEST also maintains a Medicaid Ombudsman for members who need help with referral disputes.9Med-QUEST. Medicaid Ombudsman