Original Effective Date:
08/01/1999
Current Effective Date:
03/01/2019
Inquiries
HMSA QUEST Integration welcomes any questions members may have about their health plan, our operations, our partners, and their relationship with us. We will answer any questions they may have. Or they may want to let us know how we are doing.
If during an inquiry a member expresses dissatisfaction, the member, member's authorized representative, or a provider acting on behalf of the member with the member's consent, will be given his/her grievance or appeal rights.
Grievances and Appeals
If members have questions, suggestions, or a grievance about QUEST Integration services, we can help them with most of their questions over the phone. They may call us, or they may send their inquiries in writing.
Sometimes members are not happy with our responses to their questions. We will inform the member, their authorized representative or their provider who may be acting on their behalf with the member's consent, of the member's grievance and appeal rights. They may call us and so we can guide them through the process. Our staff may assist in writing a summary of the grievance or appeal.
There are times when members may want their doctor or someone else to represent them. Members may call and tell us who it is, but to help us know that we have the right person, members should be prepared to give their consent in writing.
For members whose first language is not English, we will be able to give the answers in their native language either through a written translation or an oral interpretation. For those who are hearing impaired and a TTY user, call 1 (877) 447-5990 toll-free for help.
The grievance or appeal will be reviewed by someone who has not been involved in deciding anything about the member's case at any level.
For an appeal that deals with clinical services, such as medical, behavioral health, and long-term services, or an administrative denial for children under age 21, a health plan medical director will review the case. This is especially for:
- A grievance or appeal that deals with clinical issues,
- An appeal that approves a service that is less than the service requested,
- A grievance that deals with a review of an expedited appeal, or
- An appeal of a denial due to lack of medical necessity.
All administrative denials for children (under age 21) shall be reviewed and approved by the medical director.
Grievances
When to File
Members may file a grievance if they are not happy with:
- The quality of the care or service provided.
- The way our staff treated them.
- Their doctor and how they were treated by the doctor or the doctor's staff.
- The way their rights were not respected.
Who Can File
The member, a person they choose, or their doctor can file a grievance either verbally or in writing. We need verbal consent from the member before we can interact with their authorized representative or their doctor. The member or their authorized representative must give us written consent before a doctor can file a grievance on their behalf.
We Will Help Member Write Their Grievance
If the member needs help writing a grievance, we can help. Our grievance coordinator can write a summary of the member's grievance and get the member's consent when they want someone else to represent them.
We can also get interpreter services for members who do not speak English as their native language. Members who are hearing impaired and a TTY user, call 1 (877) 447-5990 toll-free.
The grievance must include:
- Member's name, address, phone number, and HMSA membership number,
- The date of the grievance,
- An account of the facts to support the grievance, and
- Copies of any related records or papers. Member must keep a copy of what they send to us for their records. We will not return the documents to the member.
Timeframe for Our Response
Members may submit their grievance at any time. There is no time limit.
We have 5 business days from the date we received their grievance to let them know that we received it.
We have 30 calendar days from the date we received their grievance to give them a decision. We will inform them in writing of the results of the decision and the date when the decision was made.
Grievance Decision
Once we decide, we will tell the member in writing. It will include our decision and the date the decision was made. We will also explain the reason for our decision. Along with our decision, we will tell them about their right to file a grievance review with DHS. Our decision is final unless the member chooses to file a grievance review.
When Member Disagrees – Asking for a State Grievance Review
When to File
If the member is not happy with our grievance decision, they can ask for a grievance review from DHS, Med-QUEST Division.
How to File
- By phone; member may call DHS, Med-QUEST Division, at (808) 692-8094 on Oahu.
- By mail; member may write to the DHS, Med-QUEST Division, at:
Med-QUEST Division
Health Care Services Branch
P.O. Box 700190
Kapolei, HI 96709-0190
Timeframe
Member has 30 days from the date they receive our decision to ask for a State grievance review.
Grievance Review Decision
The DHS, Med-QUEST Division, will respond within 90 days after receiving the member's grievance review request. The grievance review decision made by the DHS, Med-QUEST Division, is final.
Appeals
When to File
Members may file an appeal with us when one of the following actions has occurred:
- The service requested was denied or restricted.
- The authorization for a service was terminated, suspended, or reduced.
- Member not happy with their health care services because they weren't timely, there were unreasonable delays, or the grievance or appeal decision was not carried out in a timely way.
- Member does not agree with a payment that was denied or reduced.
Who Can File
The member, an authorized representative, or their doctor can file an appeal either verbally or in writing. We need a verbal consent from the member before we can interact with their doctor or member representative. The member or their authorized representative must give us written consent before a doctor can file an appeal on their behalf.
When someone requests an appeal for a member, they must be an "authorized representative." To have an authorized representative, the member must file a form with us with the person's name. Members may call us to request the form and/or if they need help writing the appeal.
The appeal request must include:
- Member's name, address, phone number, and HMSA membership number,
- The date of the appeal,
- An account of the facts to support the appeal and why they do not agree with our decision, and
- Copies of any related records or papers. Member must keep a copy of what they send to us for their records. We will not return the documents to member.
Members have the right to ask to review their case file, including medical records and any other documents that are part of their appeal.
We Will Help Member Write Their Appeal
Appeals can be made orally or in writing. If the member needs help writing an appeal, we can help. Our grievance coordinator can write a summary of member's appeal and get their consent when they want someone else to represent them.
We can also get interpreter services for those who do not speak English as their native language. Those who are hearing impaired and a TTY user, call 1 (877) 447-5990 toll-free.
Timeframe for Our Response
Member may file an appeal within 60 days of the notice of action. We have 5 business days from the date we received the appeal to let them know that we received it.
We have 30 calendar days from the date we received the appeal to give them our decision. We may give a response sooner if the member's health condition requires a quick response.
Should we need more time to make our decision, we will let the member know in writing why and what additional information is required.
If this happens, we will add up to 14 more calendar days to our response time. Member can also request an extension.
We may give the member a response sooner if their health condition requires a quick response. We will tell them in writing the results of the decision and the date when the decision was made.
Appeal Decision
Once we decide, we will tell the member in writing. It will include our decision and the date the decision was made. We will also explain the reason for our decision. Along with our decision, we will tell them about their right to request a state administrative hearing and what steps need to be taken.
Grievance Coordinator Contact Information
Use the following methods to send a grievance or appeal:
Mail:
HMSA QUEST Integration
Member Advocacy & Appeals
P.O. Box 1958
Honolulu, HI 96805-1958
E-mail:
ga_help@hmsa.com
Phone:
• (808) 952-7843 or toll free 1 (800) 440-0640
Fax:
• (808) 948-8224 or (808) 952-7546
Expedited Appeals
When to File
You may file an expedited appeal if the standard appeal timeline:
- Could seriously jeopardize the member's life or health,
- Could seriously jeopardize the member's ability to attain, maintain, or regain maximum function, or
- Could subject the member to severe pain that cannot be managed without the care or treatment that is being requested.
We will let DHS know within 24 hours after we receive a request for an expedited appeal.
Who Can File
The member, an authorized representative, or their doctor can file an expedited appeal either verbally or in writing. We need a verbal consent from the member before we can interact with their doctor or member representative. The member or their authorized representative must give us written consent before a doctor can file an expedited appeal on their behalf.
When someone requests an expedited appeal for a member, they must be an "authorized representative." To have an authorized representative, you must file a form with us with the person's name. Members may call us to request the form and/or if they need help writing the expedited appeal.
No punitive action will be taken against a provider who requests an expedited appeal or who supports a member who files an expedited appeal.
The expedited appeal request must include:
- Member's name, address, phone number, and HMSA membership number,
- The date of the expedited appeal. For requests received orally, the date will be the date of the inquiry.
- An account of the facts to support the expedited appeal, and
- Copies of any related records or papers. Member must keep a copy of what they send to us for their records. We will not return the documents to member.
Please use the Grievance Coordinator's Contact Information noted earlier in this chapter to file a member's expedited appeal request.
We Can Help Member Write Their Expedited Appeal
If the member needs help writing an expedited appeal, we can help. Our grievance coordinator can write a summary of their expedited appeal and get their consent when they want someone else to represent them.
We can also get interpreter services for those who do not speak English as their native language. Those who are hearing impaired and a TTY user, call 1 (877) 447-5990 toll-free.
A written request is not required when an oral request has been made.
Timeframe for Our Response
Member may file an expedited appeal within 60 calendar days of the date of the denial notice.
We have no more than 72 hours from the date we receive the expedited appeal request to give our decision.
Should we need more time to make our decision, we will let member know in writing why and what additional information is required.
We will report our request for an extension to DHS and show how this delay will be in your best interest. If this happens, we will add up to 14 more calendar days to our response time. We may give the member a response sooner if their health condition requires a quick response. The member may also send us a request for an extension.
Denial of Expedited Appeal Request
If an expedited appeal was requested, but we decide that one is not needed, we will call and inform member in writing. The information we share will include that the appeal is being reviewed as a standard appeal and we will provide how to file a grievance if the member is not happy with our decision.
Expedited Appeal Decision
Within 72 hours from the time we receive your request, we will inform member in writing the results of the decision and the date the decision was made. We will make every reasonable effort to tell the member of our decision by phone, followed by a written notice.
For decisions that are not all in the member's favor, the decision notice will explain their rights to request:
- A state administrative hearing and instructions on how to file.
- An expedited state administrative hearing and instructions on how to file.
- Continuity of benefits while the hearing is pending and how to make this request.
Members will also be informed that they may be held liable for the cost of benefits paid during the hearing if the state's decision is not in their favor.
DHS State Administrative Hearing
Member may ask for a DHS state administrative hearing if they are not happy with our appeal decision. The request must be in writing. Member must submit the request to DHS Administrative Appeals Office within 120 days from the time you received our appeal decision.
Send the request to:
State of Hawaii Department of Human Services
Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809-0339
DHS will make its decision within 90 days from the date the request was filed. The DHS administrative hearing decision will prevail and be in effect.
Expedited DHS Administrative Hearing
Member may file for an expedited hearing with DHS only when we denied their expedited appeal. Member must send a request to DHS within 120 days from the date they received our decision.
Send the request to:
State of Hawaii Department of Human Services
Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809-0339
DHS will decide on the member's request within 3 business days after they filed their request. DHS will not extend this deadline. We will send DHS the information that was used to make our decision within 24 hours from the time of the denial.
Continuation of Benefits
Member has the right to request that we continue to pay for covered services when:
- Member filed their appeal or expedited appeal within 10 days from the mail date of the denial or before the effective date of the proposed adverse action.
- The appeal or expedited appeal has to do with ending, suspending, or reducing treatment that had been approved before.
- The services were ordered by the authorized provider, and the original authorization period has not ended.
To request to continue coverage while the appeal is being decided, member may contact us. If the appeal or expedited appeal decision is upheld, the member may have to pay us back for the services they received during the review period.
