Request for External Review by an Independent Review Organization

Download

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