• Can a claim be reconsidered?
• What if I am still not satisfied with the final decision of my reconsidered claim?
• What if I am still not satisfied with the final decision of my appeal?

 

Q. Can a claim be reconsidered?
A. If you would like a claim reconsidered for any reason, contact Customer Services. We will attempt to resolve all concerns promptly.

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Q. What if I am still not satisfied with the final decision of my reconsidered claim?
A. If you are not satisfied with our response to your concern, you may file a formal appeal. The appeal must be filed within one year of the date UHA informed you of the denial or limitation of the claim or coverage for any requested service. Customers may appoint someone to represent them during the appeal process, such as a guardian or legal representative. Appeals and representative appointments must be submitted in writing to:

UHA Appeals Coordinator
700 Bishop Street, Suite 300
Honolulu, HI 96813

Your appeal will be reviewed by staff not involved in the original decision (nor a subordinate to the original decision maker). If the appeal concerns a clinical matter, it will be reviewed by an independent licensed practitioner with appropriate expertise and experience. If we need additional information to complete our review, we will notify you and give you reasonable time to respond.

For more information, please view How to Initiate An Appeal.

The final decision will be made by the UHA Appeals Committee. You will be notified of the final decision within 60 days of receipt of your written appeal, or within 30 days if your appeal concerns a denial of a clinical matter.

Expedited Appeals
A member, a member's legal representative, or the member's treating provider can request an expedited appeal (72-hour response time for UHA’s final internal determination):

• 1. For an acute or urgent condition; or
• 2. If the standard time (30 or 60 days, as set forth above) for completing an appeal would
• seriously jeopardize the member's life or health
• seriously jeopardize the member's ability to gain maximum functioning; or
• in the opinion of a physician with knowledge of the appellant's medical condition, subject the member to severe pain that cannot be adequately managed without the care or treatment requested.
To request an expedited appeal, a member, member's representative, or member's treating provider, should contact Health Care Services. All necessary information regarding such urgent appeal may be submitted by telephone, fax, or other expeditious means. 

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Q. What if I am still not satisfied with the final decision of my appeal?
A. If you are not satisfied with the final decision of the UHA Appeals Committee, you have the following external appeal rights:

If you disagree with an appeals decision regarding medical necessity and experimental or investigational services, you may request external review of the decision by an Independent Review Organization (IRO) assigned by the State of Hawaii Insurance Commissioner. This request must be submitted in writing to:

Hawaii Insurance Division
Attn: Health Insurance Branch – External Appeals
335 Merchant Street, Room 213
Honolulu, HI 96813

Your request must include the following documents:

• Request for External Review by IRO
• External Review HIPAA Authorization Form
• Disclosure for Conflicts of Interest Evaluation

If you do not elect to request review by an IRO, or if you disagree with an appeal of any other decision, your options for external review vary depending on your plan. For more information, please view If You Disagree With Our Final Appeals Decision.

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