Appeals and Grievances
Grievance and Appeal Procedures
Please let us know right away if you have any questions, concerns or problems with your covered services or the care you get.
This section will explain how you can express your concerns.
There Are Two Types of Concerns:
Federal law 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 grievance 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.
A grievance is when you call or write to complain about a provider, the plan and/or service. Complaints may be about:
- 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. Your service coordinator/agency or health provider can also file a grievance for you if you authorize them to do so. Call Customer Services toll-free at 1-888-846-4262 (TTY 711) or Fax: 1-813-865-6861. Or write to:
'Ohana Health Plan
Attention: Grievance Department
949 Kamokila Boulevard, 3rd Floor, Suite 350
Kapolei, HI 96707
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 got it. We will make a decision within 30 days.
When Can I File a Grievance?
You can file a grievance at any time.
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 of when you get your response letter from us. To ask for this review, call or write to the Med-QUEST Division at:
Health Care Services Branch
P.O. Box 700190
Kapolei, HI 96709-0190
O'ahu: 1-808-692-8094 (TTY 711)
Neighbor islands: 1-800-316-8005 (toll-free) (TTY 711)
Someone will review the grievance and respond within 90 days.
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 you or your doctor 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 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 a resolution on a grievance in the required time frame
- If we do not agree to let you see a doctor that is not in our network and you live in a rural area or in an area with limited doctors.
You will get a letter from us when any of these actions occur. This letter 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 get your Notice of Adverse Benefit Determination. You can file by calling or writing to us. If you call, you must follow up with a written, signed appeal. If needed, we can help you file your appeal. You can also get help from others. Your provider or someone else you approve (in writing) to act for you can help.
Call Customer Service toll-free at 1-888-846-4262 (TTY 711). Or write to us at:
For appeal requests for medical services:
'Ohana Health Plan
Attn: Appeals Department
P.O. Box 31368
Tampa, FL 33631-3368
For appeal requests for pharmacy medications:
'Ohana Health Plan
Attn: Pharmacy Medication Appeals Department
P.O. Box 31398
Tampa, FL 33631-3398
We will send you a letter within 5 business days from when we get your appeal. This letter will let you know we got 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.
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 physical or mental 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. If your request was filed verbally, written notice is not needed. 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 a written notice of the decision
- Inform you verbally and in writing that you may file a grievance about the delay or denial of the expedited process
- Resolve the appeal as quickly as your health condition requires and no later than the date extension expires
What If I Would Like to Submit Additional Information?
You or someone appealing for you may give us more information. You may do this any time in the appeal review process. You also may review your appeal file any time during and/or after the review of your appeal.
You can also ask us for up to 14 more days 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 take more time, we will send you a letter within two calendar days letting you know and 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 Hawaiʻi 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:
State of Hawai'i Department of Human Services
Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809-0339
At the DHS Administrative Hearing, you may represent yourself. However you may also use legal counsel, a relative, a friend or other spokesperson to represent you. The DHS 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 Medical 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 a State Administrative Hearing involves an action we are taking to stop 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
Our decision on your appeal may be a denial. It may also be the State's decision (if you asked for an Administrative Hearing). If so, we may ask you to pay for the services you got while waiting for the decision.