Appealing a Precertification Denial

A behavioral health care provider may appeal a Magellan Hawaiʻi initial denial of benefits for a proposed service that requires precertification, such as Two-for-one Benefit Exchange. The appeal must be made within one year of the denial decision. Magellan Hawaiʻi manages behavioral health care for QUEST, commercial, FEP and Fed 87 members.

Routine Inquiries

• A provider may also request to speak with the physician reviewer or the behavioral health reviewer who made the original decision, or with another reviewer who was not involved in making the original determination. The reviewer may request additional information from the provider. (Also see Medical Necessity and Level of Care.)
• To initiate an inquiry, contact HMSA's Behavioral Health Services QUEST Integration (Magellan Hawaiʻi) or HMSA's Behavioral Health Services - Commercial, FEP, Fed 87 (Magellan Hawaiʻi).

First-Level Standard Appeal

HMSA Private Business or HMSA QUEST Reviews

If the behavioral health care provider is dissatisfied with HMSA's determination, the provider may appeal the decision by contacting the HMSA Appeals Unit.

HMSA's Appeals Unit will respond to the appeal as expeditiously as the member's health requires, but no later than 30 calendar days from its receipt of the request.

• The appeal request, case documentation, and any additional information are reviewed by an HMSA Medical Management clinical advisor who was not involved in making the original decision and, if necessary, by a consultant from the appropriate specialty.
• Both the provider and member are notified in writing of the appeal decision. If the denial determination is upheld, the letter will explain the provider's right to request a second-level appeal (see Second-Level Standard Appeal, below).

Expedited Review

• If the member's health, life, or ability to gain maximum functioning may be seriously jeopardized in the course of the 30 calendar days needed for standard appeal or if the member would be subjected to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal, the provider may call for an expedited review.
• A decision is made within 72 hours of the call; the provider is notified by phone, followed by a letter.

Second-Level Standard Appeal

If a provider is not satisfied with HMSA's first-level appeal decision, they may appeal further. A provider may request review by an Independent Review Organization (IRO) or by HMSA's Appeals Committee.

Independent Review Organization Review

• The case is sent to an IRO. Neutral, independent experts consider the appeal and render a decision.
• The provider is notified in writing of the IRO's decision. If the IRO's decision upholds the denial, the case is forwarded to HMSA's Appeals Committee for further review.

HMSA or HMSA QUEST Reviews

• The case is submitted to HMSA's Appeals Committee, which is composed of practicing physicians and community members appointed by HMSA's Board of Directors.
• A provider may appear before the committee to present evidence or testimony and may bring a provider specialist or sub-specialist.
• Both the provider and member are notified in writing of the decision. If the decision upholds the original denial, the provider may request arbitration (see Arbitration below).

Arbitration

If the provider is not satisfied with the second-level appeal decision, they may request arbitration. The arbitration is subject to the following conditions:

• Both parties must agree on the arbitration service.
• Costs for the arbitrator and arbitration services are shared equally.
• The written arbitration decision is binding.

Physician Appealing a Precertification Denial

Non-Physician Appealing a Precertified Denial

Revision History