HAWAII

If your insurer denies your claim, you have the right to an internal appeal.^[1] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

• Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
• Collect information. In addition to the determination letter, collect all the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
• Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
• Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
• Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
• Request an expedited appeal, if applicable. You may request an expedited internal appeal if waiting 60 days for your requested treatment would seriously jeopardize your life, health, or ability to regain functioning, or would subject you to severe pain that could not be adequately managed.^[2] If you believe you qualify for an expedited appeal, you should contact your insurer and ask for instructions on how to request one.^[3]
• Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion. 

The internal appeals process should take a maximum of 60 days.^[4] An expedited internal appeal should take no more than 72 hours after the request is submitted.^[5]

During an external review, an independent third party reviews your insurer’s decision.[6] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Under Hawaii law, you are entitled to request an external review in the following if your insurer still denies you coverage after the conclusion of an internal appeal.^[7]

You can also request an expedited external review if waiting 60 days would seriously jeopardize your life, health, or ability to regain functioning. You can request an expedited external review while you request the expedited internal appeal.^[8]

You should submit your request for external review to the Hawaii Division of Insurance (“Division”) within 130 days from of your insurer’s last determination letter.^[9] To request an external review, you should take the following steps:

• Request documents from your insurer. Ask your insurer for a copy of the final determination letter from the internal appeal, a signed consent to release your medical records, and a conflict of interest disclosure form.^[10]
• Prepare a cover letter. Prepare a cover letter to the Division. The cover letter should contain the following information:
• Whether you are requesting a standard or an expedited external review;
• An explanation, in detail, why you believe you are entitled to the coverage or reimbursement that you are seeking;^[11] and
• An explanation of why you believe the denial of coverage in your case was wrong.^[12]
• Send a filing fee. You should send a check for $15, made payable to the “Department of Commerce and Consumer Affairs” along with your applicable. The filing fee is refundable if the Division determines that your insurer should have covered your claim.^[13]
• Submit your request. Send your request for an external review and supporting documents to the Division at the following address:
• Division of Insurance
  P.O. Box 3614
  Honolulu, HI 96811

The external review process should take no more than 45 days after receiving your request.^[14] If you requested an expedited external review, the process should take no more than 72 hours after receiving your request.^[15]

If you are a Hawaii resident and your insurer denies your coverage after the external review process, you should speak with an investigator within the Division to determine if an informal resolution is possible. You can speak with an investigator by calling (808) 586-2790 between the hours of 7:45 a.m. and 4:30 p.m., Monday through Friday.^[16]

If an informal resolution is not possible, you can file a complaint with the Insurance Division.

Complaint information. You can find a copy of the complaint form here. Your complaint should include the following information:

• The name, age, address, email address, and telephone number of the person filing the complaint (“Complainant”);
• The name of the insured individual, if different from the Complainant;
• The names of any other parties involved in the claim (for example, the plan administrator);
• The name of insurance company and the type of insurance;
• The policy number, certificate number, claim number, date of loss or service, and reason for the complaint;
• What you consider to be a fair resolution.^[17]

Supporting documents. You should submit the following documents as supporting information:

• A copy of your insurance card;
• Copies of coverage denials or adverse benefit determinations from your insurer;
• Copies of any determinations made by internal and external reviewers;
• Any materials submitted with prior appeals and complaints;
• Supporting documentation from your health care provider;
• A copy of your insurance policy; and
• All responses from your insurer. ^[18]

How to submit. You can submit the complaint and supporting documents by fax to (808) 587-5379 or by mail to:

Hawaii Insurance Division
Health Insurance Branch
P.O. Box 3614
Honolulu, HI 96811^[19]

The Division will investigate your claim and attempt to resolve it with your health insurer. The Division can force your insurer to comply with your insurance policy, issue a citation, or fine the insurer for failure to comply. The Division can also force the insurer to reimburse you for your time and any fees you incurred in filing the complaint.

You can contact the Hawaii Division of Insurance at (808) 586-2790. The Division is open from 7:45 a.m. to 4:30 p.m. Monday through Friday.