The information in this section pertains to provider procedures for filing grievances and appeals. Providers acting on behalf of members in submitting their grievances or appeals should refer to QUEST Integration - Member Inquiry, Grievance and Appeal Process.
Reconsiderations
If you believe a claim of service should not have been denied or if you disagree with the amount of a claim payment, you may submit a request for reconsideration.
Requests for reconsideration of a processed claim must be submitted within 60 days of the date the claim was reported on your Report to Provider. If you need to change the claim information (e.g., member number, procedure code, service date, provider number, etc.), please submit a corrected claim for adjustment processing, labeled "ADJUSTMENT" in the upper right corner to ensure appropriate handling. Details for submitting adjustment claims are under "Adjustment Claims" at the beginning of this section of the handbook.
If the claim information was correct and you would like the claim to be reconsidered with no changes to the claim, call QUEST Integration Provider Service at (808) 948-6486 on Oahu or toll-free from the Neighbor Islands at 1 (800) 440-0640. You may also send written inquiries to:
ATTN: Provider Service Unit
HMSA - QUEST Integration Operations
P.O. Box 3520
Honolulu, HI 96811-3520
A provider service representative will review the information on file. If the information on file indicates that the original claim was processed incorrectly, the claim will be reprocessed. If the original processing determination is upheld, providers will be notified and given information on the appeals process should they wish to pursue the issue further.
Any determination that a service or supply does not meet medical or clinical payment determination requirements will be made by an HMSA medical director. The physician requesting the review may ask to speak to a medical director.
A follow-up inquiry may be initiated if the physician subsequently provides additional information.
Complaints
A complaint is a provider's written or verbal statement about issues related to his/her role as a provider, to a class of providers, and/or to all providers; or a complaint reported on behalf of members. Complaint categories and examples of complaints include:
- Benefits and Limits - Drug formulary, limits on adult behavioral health services.
- Eligibility/Enrollment - long wait times or inability to confirm enrollment or identify the PCP.
- Member Issues:
- Member fails appointments, does not call for cancellation, and is consistently late.
- Interaction with the member is not satisfactory. The member does not understand and/or follow instructions.
- The member is rude or unfriendly.
- Other pertinent member related issues.
- Health Plan Issues:
- Difficulty contacting HMSA or its subcontractors by telephone, long wait times, busy lines, telephones not answered.
- HMSA staff/subcontractor staff is rude, unfriendly.
- Delay in getting authorization for needed service/item from HMSA or subcontractor.
- Delay, denial or incorrect claims payment.
- Other health plan issues.
Timeframe for Filing a Complaint
You may register a complaint within 60 days after:
- HMSA’s Report to Provider (payment notice)
- Any denial or determination letter
- Date of service or incident
Submit in writing or voice complaints to QUEST Integration Provider Service at:
ATTN: Provider Service Unit
HMSA - QUEST Integration Operations
P. O. Box 3520
Honolulu, HI 96811-3520
― or ―
Phone: (808) 948-6486 or
1 (800) 440-0640 toll-free
Fax: (808) 948-8224 or
1 (800) 948-8334 toll-free
HMSA will resolve or respond to your complaint within 60 days from receipt of the complaint. If the determination is favorable, you will be informed by telephone or in person. If the determination is not favorable, you will be informed in writing. The letter will include information on how to file a grievance if you are not satisfied with the explanation given. Grievance procedures are also included in this section.
Types of Grievances
Grievances about issues related to a provider's role as a provider, to a class of providers, and/or to all providers.
The following categories of these types of grievances include:
- Benefits and Limits: (i.e., limits on behavioral health services or formulary)
- Eligibility/Enrollment: (i.e., long wait times or inability to confirm enrollment or identify the PCP)
- Member Issues: (members who fail to meet appointments or do not call for cancellation, instances in which interaction is not satisfactory; instances in which the member is rude or unfriendly; or other member-related concerns.
- Health Plan Issues: (i.e., difficulty contacting HMSA QUEST Integration or its subcontractors due to long wait times, busy lines, etc.; problems with HMSA QUEST Integration/Subcontractor staff behavior; delays in claims payment; denial of claims; claims not paid correctly; or other health plan issues)
Grievances expressing dissatisfaction with the plan's operations, activities or behavior.
These types of grievances are written statements by a provider (participating or non-participating)
- Quality (i.e., another provider did not appropriately evaluate, diagnose, prescribe or treat the member; another provider has issues with the cleanliness of office, instruments, or other aseptic technique was used; another provider did not render services or items which the member needed; or a provider reports HMSA's specialty network cannot provide adequate care for a member)
- Accessibility/Availability (i.e., delays in obtaining or inability to receive emergent/urgent services; medications; specialty care; ancillary services such as transportation; medical supplies, etc.)
- Delivery of Services (i.e., PCP did not refer member to a specialist; medication was not provided by a pharmacy; member did not receive the service the provider believed were needed; provider is unable to treat member appropriately because member is verbally abusive or threatens physical abuse.)
Timeframe for Filing and Resolving Grievances
You must register a grievance anytime after:
- HMSA's Report to Provider (payment notice)
- Date of service
Grievance Intake Process
Grievances about issues related to their role as a provider, to a class of providers, and/or to all providers
These types of grievances may be submitted in writing or verbally by a provider (participating or non-participating).
The HMSA QUEST Integration Provider Services (PS) Unit will conduct the intake and processing of these types of grievances for all islands.
Submit in writing or voice complaints to QUEST Integration PS at:
ATTN: Provider Correspondence Unit
HMSA - QUEST Integration Operations
P. O. Box 3520
Honolulu, HI 96811-3520
– or –
Phone: (808) 948-6486 or toll free 1 (800) 440-0640
Fax: (808) 952-7546 or (808) 948-8224
Grievances expressing dissatisfaction with the plan's operations, activities or behavior
These types of grievances must be received in writing and directed to the Grievance Coordinator for processing.
A grievance written by a provider must include:
- Provider's name, address, phone number
- HMSA provider number
- A description or explanation of the grievance, including the member's name and member number, if applicable
- Copies of related letters, reports or papers
Submit your request in writing for these types of grievances to the QUEST Integration Grievance Coordinator at:
ATTN: Grievance Coordinator
HMSA QUEST Integration
P. O. Box 1958
Honolulu, HI 96805-1958
– or –
Phone: (808) 952-7843 or toll free 1 (800) 440-0640
– or –
Fax: (808) 952-7546 or (808) 948-8224
Upon receipt, the Grievance Coordinator will ensure that all necessary information has been provided and/or will follow up to obtain necessary information to process the grievance.
An acknowledgement letter from the Grievance Coordinator will be sent to you within 5 business days after receiving the written grievance. The acknowledgement letter will include language informing you that a response will be sent within 60 calendar days of receipt of your written grievance.
The Grievance Coordinator will refer the case to respective internal areas, and will document indicating a grievance was received and whom the grievance was forwarded to for review.
Grievance Resolution Process
Overall review of grievances will be performed by PS.
Review of a written grievance will be performed by a party not involved in making the original determination.
The Grievance Coordinator is not involved in making original determinations or in the daily processing of claims.
All internal records and correspondence related to the case will be researched and reviewed.
Additional information will be requested from provider as required.
- If there is a delay in getting any information, PS will notify the provider.
- If additional information is needed from the provider, PS will request it.
If a grievance involves a medical or clinical question, an HMSA Medical Director, peer reviewer or specialist consultant who was not involved in the initial determination and who is not a subordinate of any individuals involved in the initial determination. At least one person will review the appeal who is a practitioner in the same or similar specialty who typically treats the medical condition, performs the procedure or provides the treatment and is board-certified.
Grievance Determination Notification
HMSA will resolve or respond to your complaint within 60 days from receipt of the grievance. If the determination is favorable, you will be informed by phone or in person. If the determination is not favorable, you will be informed in writing of the decision and information on how to file for an administrative appeal.
Your request for appeal must include the following information: Provider's name, address, phone number, a description or explanation of the problem or complaint, including the member's name and number, and if applicable, copies of related letters, reports, or papers.
Appeals
An appeal is undertaken if the provider (participating or non-participating) is not satisfied with the determination made at the grievance level.
Timeframe for Filing and Resolving an Appeal
You have 30 days from the date of the grievance determination letter to request an appeal. Submit your appeal in writing to the QUEST Integration Grievance Coordinator at:
ATTN: Grievance Coordinator
HMSA QUEST Integration
P.O. Box 1958
Honolulu, HI 96805-1958
The Grievance Coordinator will prepare the information that has been provided and/or will follow up to obtain necessary information to process the appeal. The case will then be forwarded to the Member Advocacy and Appeals (MAA) Department.
An acknowledgement letter from MAA will be sent to the provider within 5 business days from the date of receipt. The acknowledgement letter will include language information to you that a response will be sent within sixty (60) days of HMSA's receipt of the written appeal.
MAA will refer the appeal to a Medical Director, peer reviewer or specialist consultant who was not involved in the initial determination and who is not a subordinate of any individuals involved in the initial determination. At least one person will review the appeal who is a practitioner in the same or similar specialty who typically treats the medical condition, performs the procedure or provides the treatment and is board-certified.
All appeal determinations will be in writing. If the determination is unfavorable, your next level of appeal is arbitration.
Arbitration
If you are not satisfied with the results of the appeal, you may request for arbitration in accordance with your HMSA QUEST Integration Participating Physician Contract within 60 days from the date of the written appeal determination. Non-participating providers are not eligible for arbitration. Arbitrations are handled by HMSA's Legal Services Department. Your request for arbitration must be sent in writing to the following address:
HMSA Legal Services
P.O. Box 860
Honolulu, HI 96808-9988
Confidentiality
All information pertaining to a provider's grievance and appeal will be kept confidential.
Access to a provider's file is limited to persons or agencies which require this information in order to perform their duties in accordance with HMSA's QUEST Integration contracts with the State. Access is permitted to Department of Human Services (DHS) and other individuals or entities as may be required by DHS.
Access is permitted to any other party only after complying with the requirements of State and Federal laws regarding such access, e.g., responding to a subpoena.
The provider may also provide written permission for HMSA to release information to another party.
Information in summary, statistical, or other form that does not identify particular individual providers may be disclosed without release or permission from providers.
