Form Instructions
Member Appeals
An appeal is when you want us to reconsider a decision we’ve made about health
plan or prescription drug coverage for services or benefits you’ve received.
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 your
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 your Evidence of Coverage for detailed information about the fast appeal process.
Instructions
Medicare appeals forms:
Please print out and complete the appeal form and mail or fax it to our appeals coordinator
at the address below.
To review your appeal, we’ll need the following information:
- Your full name.
- Your 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.
- Personal Authorization, if applicable.
Sign and date the form and mail it to:
HMSA Member Advocacy & Appeals
P.O. Box 1958
Honolulu, HI 96805-1958
Or fax to: (808) 952-7546 or (808) 948-8206
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 appeal for a future health plan service, 60 calendar days for a past service, or seven calendar days for a prescription drug. You can also request a fast appeal if your health is in
jeopardy.
