Whom to contact:

The Hawaii Insurance Division – Health Insurance Branch

Who can appeal:

You, your provider (with consent), or your authorized representative

What you can appeal:

Denials of coverage or payment for services the health plan determines are not medically necessary or are experimental or investigational.

When you can appeal:

The written request must be received within 60 days of the date of the health plan’s final internal determination.

What to send:

A written request for review

What you must pay:

No charge

What will happen:

1. Your health plan will send any documents to the reviewer within 7 days of notification (within 48 hours for an expedited review).
2. The insurance commissioner will appoint a 3-member review panel.
3. For disputes involving less than $500, the insurance commissioner may conduct a review without appointing a review panel.
4. A review hearing will be conducted within 60 days of the original request.
5. The review panel will decide whether your health plan acted reasonably by a majority vote.
6. The commissioner of insurance will issue an order affirming, modifying, or reversing the health plan’s decision within 30 days of the hearing.

When you will get a decision:

Within 90 days of the request for review

In urgent situations:

For an expedited review, the health plan must send documents within 48 hours and the review must be completed within 72 hours.