Skip to Main Content

Appeals and Grievances

We want you to let us know right away if you have any questions, concerns or problems with your covered services or the care you receive. This section will explain how you can express your concerns.

There are two types of concerns. They are called:

The state allows you to make a grievance if you have any problems with the plan. The State has also helped to set the rules for making a complaint and what we must do when we get one. If you file a grievance or an appeal, we must be fair. We cannot disenroll you or treat you differently because you made a grievance.

What is an Appeal?

An appeal is a request you can make when you do not agree with our decision about the health care you are getting and/or our timeliness. You can request an appeal when any of the following actions occur:

  • If we deny or limit a service request your health care provider asks us to approve
  • If we reduce or stop services you have been getting that we already approved
  • If we do not pay for the behavioral health care services you get
  • If we fail to give services in the required time frame
  • If we fail to give you a decision on an appeal you already filed in the required time frame
  • If we fail to give you resolution on a grievance in the required time frame
  • If we do not agree to let you see a health care provider that is not in our network and you live in a rural area or in an area with limited providers

You will get a letter from us when any of these actions occur. This is called a “Notice of Adverse Benefit Determination” You can file an appeal if you do not agree with our decision.

How Do I File an Appeal?

You must file your appeal within 60 days from the date you receive your Notice of Adverse Benefit Determination. You can file by calling or writing to us. If needed, we can help you file your appeal. You can also get help from others. But, we must have your written or verbal consent for this. Your provider or someone else you choose can help file an appeal. They can also discuss your appeal with us on your behalf.

For Appeals Requests for Medical Services:

Call Customer Service toll-free at 1-866-401-7540 (TTY 711). Fax to us at 1-866-201-0657 or write to us at:

'Ohana CCS Health Plan
Attn: Appeals Department
P.O. Box 31368
Tampa, FL 33631-3368

For Appeals Requests for Pharmacy Medications:

Call Customer Service toll-free at 1-866-401-7540 (TTY 711). Fax to us at 1-888-865-6531 or write to us at:

'Ohana Health Plan
Attn: Pharmacy Medication Appeals Department
P.O. Box 31398
Tampa, FL 33631-3398

Or complete the form online

We will send you a letter within five business days after we get your appeal. This letter will let you know we received it. We will then review it and send you a letter within 30 days telling you of our decision. You or someone you choose to act for you can review all of the information we used to make the decision during or after the review of the appeal

What if I Need a Fast (Expedited) Appeal?

You or your doctor can ask for a fast appeal. We will give you a fast appeal if your provider says waiting could seriously harm your health. You may ask for a fast appeal without a doctor's help. We will decide if you need a fast decision. You or your provider must call or fax us to ask for a fast appeal. Call toll-free 1-888-846-4262 (TTY 711). Fax to 1-866-201-0657. For fast appeals, we will call you when we make a decision. We will also send a letter with the appeal decision within 72 hours.

If you ask for a fast appeal and we decide that one is not needed, we will:

  • Transfer the appeal to the time frame for standard resolution
  • Make reasonable efforts to try to call you
  • Follow up within two days with written notice
  • Inform you verbally and in writing that you may file a grievance about the denial of the expedited process

What if I Would Like to Submit Additional Information?

You or someone appealing for you may give us more information. You may do this throughout the appeal review process. Your time to submit additional information for an expedited appeal is limited due to the short processing timeframe.

You can also ask us for up to 14 more days for you to provide more information. We may also ask for 14 more days if we feel more information is needed and it is in your best interest. If we ask for the extra days, we will send you a written notice. The notice will also tell you when the review will be completed.

What if I Do Not Like an Appeal Decision?

You may not like the appeal decision we make. If so, you can ask for a State Administrative Hearing. Someone you choose to act for you can also ask for one. You must do this within 120 days of receipt of the appeal decision letter. The letter will tell you how to file an appeal with the Hawai'i Med-QUEST Division. You can only ask for a State Administrative Hearing after you have gone through our complete appeals process. To do so, send your request to the address below.

State of Hawai'i Department of Human Services
Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809-0339

At the State Administrative Hearing, you may represent yourself. However you may also use legal counsel, a relative, a friend or other spokesperson to represent you. The State will make a decision within 90 days from the date the request was filed.

You may also have the right to ask for a fast (expedited) State Administrative Hearing. You may only do this when you asked for, or the Plan provided, a fast appeal review. If the fast appeal is denied, you or someone you choose to act for you can ask for the hearing. You must do this within 30 business days of receipt of the appeal decision letter. The letter will tell you how to file an appeal. To do so, send your request to the address above.

What Happens with my Behavioral Health Benefits (Services) During the Appeal or State Administrative Hearing Process?

We will continue your services if ALL of the following happen:

  • An appeal was requested within 60 calendar days from the date you receive your Notice of Adverse Benefit Determination Letter.
  • Your appeal or request for State Administrative Hearing involves an action we are taking to stop, suspend or reduce services we had already approved
  • The services were ordered by an authorized provider
  • The original time frame covered by the approval we gave has not ended yet
  • You request that we continue your services in a timely manner, defined as on or before the later of the following:
    • Within 10 calendar days of the date we mailed you the Notice of Adverse Benefit Determination Letter; or
    • The date we planned to stop or reduce your services

If our decision on your appeal or the State's decision (if you requested a State Administrative Hearing) is to deny the services, we may ask you to pay for the services you received while waiting for the decision.

What is a Grievance?

A grievance is when you call or write to complain about a provider, the plan and/or service. Grievances may include:

  • Quality-of-care issues
  • Wait times during provider visits
  • The way your providers or others act
  • Unclean provider offices
  • Not getting the information you need

How Do I File a Grievance?

You can file a grievance at any time. You or another person can file a grievance by calling or writing to us. You may also fax your grievance to 1-866-388-1769. Your service coordinator/agency or health provider can also file a grievance for you if you authorize them to do so.

You must tell us that you agree to have someone else talk for you about your grievance. Call Customer Service toll-free at 1-866-401-7540 (TTY 711). Or, write to:

'Ohana CCS Health Plan
Attn: Grievance Department
949 Kamokila Boulevard, 3rd Floor, Suite 350
Kapolei, HI 96707

Fax: 1-813-865-6861

We can help you if you speak another language.

You can also call Customer Service if you need help filing your grievance. Within 5 business days of getting your grievance, we will mail you a letter telling you we received it. We will make a decision within 30 days.

You can also request a 14 day extension if you need more time for information to support your grievance. If we need more time, we will call you to tell you why. We will also let you know by sending you a letter within two calendar days. We will do this if we need more information and it is in your best interest.

State Grievance Review

You can also ask for a state grievance review. This must be done within 30 days after you receive your response letter from us. To ask for this review, call or write to the MQD at:

Med-QUEST Division Health Care Services Branch
601 Kamokila Blvd., Suite 506A
Kapolei, HI 96709-0190

O'ahu: 1-808-692-8094 (TTY 1-808-692-7182)
Neighbor islands: 1-800-316-8005 toll-free (TTY 1-800-603-1201)

Someone will review the grievance and respond within 90 days of getting it.