Request for External Review by an Independent Review Organization

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If you have a fully insured plan (e.g., non-private, non-federal), and you do not agree with the outcome of your appeal, you can ask to have an independent review organization (IRO), selected by the State Insurance Commissioner’s office, look over your appeal. Three forms are required by the State Insurance Commissioner for an IRO review: The Request for External Review by an Independent Review Organization, the HIPPA Authorization for Release of Information form, and the Disclosure for Conflicts of Interest Evaluation. After you have completed all three forms, mail the forms to the State Insurance Commissioner.

From

Fill in your name, address, telephone number, and HMSA subscriber ID number.

Attach requested items

Read carefully and attach items 1 through 4.

Expedited review

If your request qualifies for an expedited review, read carefully and sign.

Experimental or investigational attachments

If a determination that the service under review was experimental or investigational, read carefully and attach items 1 and 2.

Once you’ve filled out the form, please mail it with all attachments to:

Hawaii Insurance Division
Attn: Health Insurance Branch – External Appeals
335 Merchant St., Room 213
Honolulu, HI 96813

Please click on the link to access the form and form instructions:

HIPAA Authorization for Release of Information
The HIPAA Authorization for Release of Information form allows HMSA to share your information with certain people.

Disclosure for Conflicts of Interest Evaluation
This form asks you to name any conflicts of interest that may come up in your appeal process.