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State guide

Hawaii

Pick the kind of plan you have to see who to call first. Hawaii can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

  • Your employer pays claims itself

    Hawaii usually cannot help with these plans. Call the Employee Benefits Security Administration.

    Call 1-866-444-3272

  • Insurance you buy, or an employer plan bought from an insurer

    Call Hawaii Department of Commerce and Consumer Affairs, Insurance Division. See the at-a-glance box.

    Regulator's website

  • Medicaid or children's coverage

    Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Hawaii.

    Medicaid in Hawaii

  • Medicare

    Hawaii State Health Insurance Assistance Program (Hawaii SHIP), Hawaii Department of Health, Executive Office on Aging gives free counseling. Or call 1-800-MEDICARE.

    Call 808-586-7299 1-800-633-4227

The short version for Hawaii

Hawaii runs its own external review through the Insurance Commissioner, with a slightly longer filing window than most states (130 days) and a $15 fee that is refunded if you win. The Insurance Division is both the regulator and the state's consumer help line for private health plans. For general questions about employer coverage required by Hawaii's Prepaid Health Care Act, the Insurance Division points people to the Department of Labor and Industrial Relations.

At a glance: independent review for plans Hawaii regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Hawaii Department of Commerce and Consumer Affairs, Insurance Division · 1-844-808-DCCA (3222)
Independent review
A state process (External review)
Deadline to request it
130 days from the date of the coverage denial (the statute counts from when you receive notice of the plan's final decision)
Cost
$15, refunded if the reviewer reverses the denial; the commissioner waives it for financial hardship, and you cannot be charged more than $60 in filing fees in one plan year
Decision time
45 days after the independent review organization receives the request; fast track: 72 hours for a medical necessity denial; up to 7 days for a denial of experimental or investigational treatment

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Hawaii does not give an insurance-card tip. The Insurance Division says its external review is for members of health plans issued by private health insurance companies, and is not available to Medicare or Medicaid members or to members of self-funded plans where the insurance company only acts as a third party administrator.

Independent (external) review

Process
A state process. Run by Hawaii Insurance Commissioner (Insurance Division), who assigns an independent review organization.
Where you file
regulator
How
Write to the Insurance Commissioner asking for an external review. Include a cover letter explaining why the plan's decision was wrong, a copy of the plan's final internal decision, a signed release of medical records, a conflict of interest disclosure (your health plan supplies the release and disclosure forms), and a $15 check payable to "Department of Commerce and Consumer Affairs." Health plan notices give the address as Hawaii Insurance Division, Attn: Health Insurance Branch – External Appeals, 335 Merchant St., Room 213, Honolulu, HI 96813.
Which denials qualify
Denials based on medical necessity, appropriateness, health care setting, level of care or effectiveness, and denials that call a treatment experimental or investigational. A denial based on a specific exclusion in the plan may not qualify.
Appeal to the plan first?
Yes, unless the health plan waives the requirement, you ask for an expedited external review at the same time as an expedited internal appeal, or the plan has substantially failed to follow its own internal appeals process.

Official page

General rules and what to send: how external review works, how to request it.

Free help in Hawaii

  • Hawaii Insurance Division, Department of Commerce and Consumer Affairs

    Answers questions about private health insurance, takes complaints against health insurers and gives advice on requesting an external review; the federal directory lists it as Hawaii's consumer help contact for insurance you buy yourself or get from a Hawaii-only employer.

    Phone: 1-844-808-DCCA (3222)

Medicare and Medicaid in Hawaii

Medicare counseling
Hawaii State Health Insurance Assistance Program (Hawaii SHIP), Hawaii Department of Health, Executive Office on Aging · Oahu 808-586-7299; toll-free 1-888-875-9229 . Free help with Medicare appeals.
Medicaid agency
Hawaii Department of Human Services, Med-QUEST Division (Hawaii Medicaid)
Fair hearing deadline
Med-QUEST must receive your request within 90 calendar days from the date of the notice. Your notice states the deadline that applies to you.
Good to know
If a Medicaid health plan made the decision, you must finish that plan's grievance and appeals process first; the 90 days then run from the plan's notice (Hawaii Administrative Rules section 17-1703.1-4). You can ask by phone, mail, in person or electronically. Med-QUEST lists 808-692-8094 for member grievances and appeals and 800-316-8005 for eligibility.

Medicaid appeals page How Medicaid appeals work

State laws that can help

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Affordable Care Act: Working with States to Protect Consumers (State External Appeals Review Processes), Centers for Medicare & Medicaid Services
  2. Hawaii Health Insurance Consumer Help, Centers for Medicare & Medicaid Services
  3. External Review of Health Plan Disputes, Hawaii Insurance Division
  4. Health Insurance Information, Hawaii Insurance Division
  5. Insurance Division home page, Hawaii Department of Commerce and Consumer Affairs
  6. Hawaii Revised Statutes section 432E-33, Request for external review
  7. Hawaii Revised Statutes section 432E-34, Standard external review
  8. Hawaii Revised Statutes section 432E-35, Expedited external review
  9. If You Disagree with Our Appeals Decision (member notice describing Hawaii external review), UHA Health Insurance
  10. Hawaii State Health Insurance Assistance Program
  11. Grievance and Appeals, Med-QUEST Division
  12. Hawaii Administrative Rules section 17-1703.1-4, Action on request for hearing (Cornell Legal Information Institute copy)
Not confirmed (8)
  • How long a standard independent review takes. 45 days is taken from a Hawaii health plan's member notice describing the state law; the statute subsection with the decision deadline was not loaded
  • How long a fast independent review takes. 72 hours and 7 days are taken from the same health plan notice, not from the statute text
  • How to file for independent review. the mailing address appears on health plan notices and forms, not on the Insurance Division's external review page
  • The independent review request form. the state publishes no request form; the Insurance Division says the release and disclosure forms come from the health plan
  • A searchable list of past decisions. none found
  • Published results of independent review. none found
  • The summary for this state. the role of the Department of Labor and Industrial Relations under the Prepaid Health Care Act is from the Insurance Division's page; that department's own contact details were not checked
  • State laws that help. only the external review law was sourced; step therapy, prior authorization and surprise billing laws were not researched to a sourced standard

Sources last checked . Found a mistake? Report it.