If a participating facility is dissatisfied with an initial claim or utilization management and quality assurance review decision made by HMSA, it may appeal by taking the following steps.
A. Initial Claim Decision
Participating facilities must request a review of HMSA's initial claim decision (e.g., payment or denial of a claim) within the time specified in their participating provider agreement.
To request a review, facilities may contact Provider Correspondence.
B. Utilization Management and Quality Assurance Review Decision
Following a utilization management and quality assurance review determination, participating facilities must follow the redetermination instructions outlined in the written notification provided to them. Utilization management and quality assurance activities include medical record reviews of inpatient admissions for short stays, readmissions, transfers, and diagnosis-specific situations. To conduct these reviews, HMSA uses nationally established clinical review criteria. As part of their participating provider agreement with HMSA, facilities agree to comply with utilization management activities as well as policies and procedures set forth in HMSA’s Provider E-Library.
Questions or correspondence should be directed to the contact designated in the written notification.
Participating facility requests for redetermination are assigned to a medical director as follows:
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- If no new information is attached, the request is reviewed by a medical director who was not involved in the initial review.
- If new information is attached, the request is reviewed by the medical director who initially reviewed the case. If the denial decision is upheld, the request is reviewed by a second medical director who was not involved in the initial review.
C. Arbitration
If a facility disagrees with HMSA’s redetermination decision, the facility must request arbitration in writing within 60 calendar days of the date of the decision. The request must be sent to:
Arbitration Request
HMSA - Legal Services
P.O. Box 860
Honolulu, HI 96808-0860
Facilities should refer to their contracts for further details regarding the conduct of arbitration procedures. Further information about the arbitration process will be provided by Legal Services in a letter acknowledging the arbitration request.
