Form Instructions
Member Appeals
If we deny any part of your request for a service or payment of a service, you may
ask us to reconsider our decision. This is called an appeal.
Standard appeal – The timeframe we have to make a decision
after we receive your request depends on whether you have already received your
care or service, or you are waiting to receive your care or service. Refer to the
Evidence of Coverage for detailed information about the standard appeal process.
Fast appeal – We must notify you by telephone and in writing
of our decision within 72 hours, or sooner if your health requires us to. Refer
to the Evidence of Coverage for detailed information about the fast appeal process.
Instructions
An appeal is when you want us to reconsider a decision we’ve made about health
plan coverage for services or benefits you’ve received.
Please print out and complete the appeal form and mail it to our appeals coordinator
at the address below.
To review your appeal, we’ll need the following information:
- Your full name.
- Your 65C Plus member number.
- A daytime telephone number where we can reach you.
- The service (laboratory tests, surgery, prescription drug, etc.).
- Your HMSA notification of preauthorization denial.
- Provider name.
- Description of the facts, including why you think our decision is in error.
- Supporting documentation, if any.
Sign and date the form and mail it to:
HMSA Appeals Coordinator
Attn: Expedited Appeal
P.O. Box 1958
Honolulu, HI 96805-1958
Or fax to: (808) 952-7546 on Oahu
We’ll notify you of our decision regarding your appeal as quickly as your
case requires, based on your health status, but no later than 30 calendar days after
receiving your complaint. You can also request a fast appeal if your health is in
jeopardy.