How to appeal an HMSA decision
Request an appeal
If you wish to dispute a determination by HMSA related to coverage, payments to providers, and any other decision or action by HMSA, you must request an appeal. An appeal is a formal way of asking HMSA to review and change a decision that has been made.
When you make an appeal, HMSA reviews the decision made to check if all available information was fully considered and that the rules of your plan were properly followed. When the review is complete, HMSA will give you a decision.
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 Appeals Unit
Appeals Coordinator
P.O. Box 1958
Honolulu, HI 96805-1958
Or send a fax to (808) 952-7546 on Oahu.
A request that does not comply with the submission requirements listed on 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.
- A court-appointed guardian or an agent under a health care proxy.
What your request must include
To be recognized as an appeal, your request must include:
- The request date.
- Your name.
- The date of the denied service, supply, or contested action or decision.
- The subscriber number on your HMSA 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 .
You should 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.
With regards to your appeal of a precertification decision, HMSA will respond to your appeal 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.
Expedited appeal
You may request an expedited appeal if the application of the time periods for appeals may:
- Seriously risk your life or health;
- Seriously risk your ability to gain maximum functioning; or
- Subject you to severe pain that cannot be managed without the care or treatment that is the subject of the appeal.
For additional important information, we encourage you to read:
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