How to appeal an HMSA decision
You have the right to appeal to HMSA if you disagree with its decisions about your plan coverage, reimbursements to you or your provider, or other decisions or actions. An appeal is a formal way of asking HMSA to review and change a decision.
When an appeal is filed, HMSA reviews whether the decision took into account all available information and that all rules of your plan were followed. When the review is complete, HMSA will decide on your appeal. If your appeal is approved, your provider will be notified. If your appeal is denied, both you and your provider will receive a letter explaining why your service was denied.
Please refer to your Guide to Benefits for the appeal process specific to your health plan coverage. Your request must be in writing unless you are requesting an expedited appeal.
Mail your request to:
HMSA Member Advocacy & Appeals
P.O. Box 1958
Honolulu, HI 96805-1958
Or send a fax to 952-7546 or 948-8206 on Oahu.
A request that does not comply with the submission requirements listed in your Guide to Benefits will not be recognized or treated as an appeal.
Who can request an appeal?
You or your authorized representative may request an appeal. Authorized representatives include:
- Any person you authorize to act on your behalf.
- To authorize another person to act on your behalf with HMSA, you must submit to HMSA the Authorized Representative Form that can be mailed to you when you request an appeal.
- If you are a Medicare member, you must submit to HMSA the Appointment of Representative form.
- A court-appointed guardian or an agent under a health care proxy.
- A person authorized by law to provide consent for you or to make health care decisions on your behalf.
- A family member or your treating health care professional if you are unable to provide consent.
What your request must include
To be recognized as an appeal, your request must include:
- The request date.
- Your name and telephone number.
- Your date of birth.
- The date of the denied service, supply, or contested action or decision.
- The subscriber number on your HMSA membership card.
- The provider's name.
- A description of facts related to your request and why you believe our action or decision was in error.
- Any other information relating to your appeal, including written comments, documents, and records you would like us to review.
Please keep a copy of your appeal for your records as your request will not be returned to you.
Appeal of an HMSA precertification decision
If your appeal relates to a claim for benefits or a precertification request, we will provide, at your request, reasonable access to and copies of all documents, records, and other information relevant to your claim, as defined by the Employee Retirement Income Security Act. There will be no charge for you to access the information.
HMSA will respond to your appeal of a precertification decision as soon as possible given the medical circumstances of your case, but not later than the number of days specified in your Guide to Benefits.
Information available from HMSA
If our appeal decision results in a denial of part or all of your request, we will provide an explanation, including the specific reason for denial, reference to the health plan terms on which our decision is based, a statement of your external review rights, and other information regarding our denial.
You may request an expedited appeal if the time periods for appeals may:
- Seriously threaten your life or health.
- Seriously threaten your ability to gain maximum functioning.
- Subject you to severe pain that cannot be managed without the care or treatment that is the subject of the appeal.
If you disagree with HMSA’s appeal decision
If you request an appeal and disagree with HMSA’s decision, you may further pursue the matter. You must do one of the following:
- Request arbitration within one year of the decision.
- Request review by an independent review organization (IRO) selected by the Hawaii insurance commissioner. If you are enrolled in a self-funded group plan, HMSA will select an IRO. You must ask for review by an IRO within 130 days of the decision if you are appealing an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness, or a determination by HMSA that the service or treatment is experimental or investigational and you meet the requirements of Hawaii Revised Statues Chapter 432E.
- File a lawsuit against HMSA under section 502(a) of the Employee Retirement Income Security Act (ERISA) if you are a member of an employer-sponsored group.
Please click here to access the forms required to submit a request for an IRO selected by the Hawaii insurance commissioner.
For further information, please review your Guide to Benefits for instructions on filing an appeal request or call HMSA Customer Relations.