Grievance and Appeal

Applicant's Appeal Rights

If you do not agree with the foregoing determination, you may call, write, use other commonly available electronic means, or visit the Med-QUEST Eligibility Branch to request an informal review meeting with the eligibility worker and/or his/her supervisor. In addition, you may request an administrative hearing with a Hearing Officer. You will be given the opportunity to present evidence in support of your position that the intended action is incorrect. You do not need to first have an informal review meeting in order to request an administrative hearing.

You must make your request for either an informal review or an administrative hearing in-person, by telephone, mail, or through other commonly available electronic means. If you wish to submit a written request, you may use the Department’s form or write your request on any paper. Your request must be received by our office within 90 calendar days from the date of this notice.

You may have someone else request, or speak, for you at the informal review or administrative hearing. This person is called an authorized representative. If you did not designate an authorized representative on your application, please provide written authorization for the person to represent you or you may use the Department’s Request for a Hearing form. The written authorization must be received by the Med-QUEST Eligibility Office in order to acknowledge any actions taken by your authorized representative. An authorized representative must agree to maintain, or be legally bound to the confidentiality of any information regarding the applicant or beneficiary that is provided by the department. An authorized representative who is a provider, staff member or volunteer of an organization must agree to sign an agreement to comply with regulations relating to confidentiality of information, prohibition against reassignment of provider claims as appropriate for a health facility or an organization acting on the facility’s behalf; must meet the authentication and data security standards required under State and federal law or otherwise specified by the department. If you choose to have an authorized representative, you may withdraw his or her name or replace the person with another authorized representative at any time.

At the informal review meeting or at the administrative hearing, you and/or your authorized representative will have the opportunity to explain why you do not agree with the decision. At your request, our office will provide you with information about a Legal Aid Office that may be able to advise or represent you at no cost. Please let us know if you need an interpreter or other aid to help you communicate with us at the informal review or administrative hearing.

H.A.R. 1703.1-2 & 1703.1-3

Contact Information:

Phone:	HOLDER
Fax:	HOLDER
Mailing Address:	HOLDER

Health Plans

AlohaCare QUEST (Medicaid) Members

Call: 808-973-0712

Toll-free: 1-877-973-0712

TTY/TDD: 1-877-447-5990

7:45 a.m. to 5 p.m.,

Monday through Friday

HMSA Quest Integration

Member Advocacy and Appeals

PO Box 1958

Honolulu, Hi 96805-1958

TOLL FREE- 1-800-960-4672

FAX: 808-948-8224

Kaiser Permanente

General information

808-432-0000

Member Services

1-800-966-5955 (toll free)

OHANA- Quest Integration

1-888-846-4262

(TTY 711)

Monday- Friday 745 am to 4:30 pm HST

OHANA – Community Care Services (CCS)

1-866-401-7540

(TTY 711)

24 hours, 7 days a week

UnitedHealthCare (UHC)

Quest Integration Program

1-888-980-8728

TTY 711

Monday- Friday 7:45 am to 4:30 pm HST

HDS Hawaii Dental Services

HDS Medicaid Customer Service

Tel: (808) 529-9347

Toll Free (855) 819-9117

Fax (808) 529-9333

IF YOU HAVE MEDICAID AND ARE not satisfied with the quality of the care or service you received, the way the health plan staff, or doctor treated you, or another matter, you file a grievance by contacting your health plan: AlohaCare, HMSA, Kaiser Permanente, Ohana Health Plan. UnitedHealthcare Community Plan, Community Care Services (CCS) or Hawaii Dental Service (HDS).

What if I am not happy with my health plan’s grievance decision?

If you are not happy with your health plan’s decision, you can request a State Grievance Review

State Grievance Review

You may ask for a State Grievance Review from Med-QUEST/Department of Human Services, Health Care Services Branch.

In order to request a State Grievance Review, you must complete the following steps:

1. You have filed a grievance with the Health Plan, CCS or HDS. (See FAQ #6)

2. You have received a Grievance Resolution Letter. If you do not have a Grievance Resolution Letter, contact your health plan, CCS or HDS.

You may request a State Grievance Review within 30 days of the date of your Grievance Resolution Letter.

To request a State Grievance Review, call 808-692-8094, leave a message, speak slowly and clearly provide the following information:

1. Your full name

2. Your last name

3. Your phone number

4. The reason for your call

5. The date of your resolution letter

Med-QUEST will return your call within 3 business days.

The outcome or resolution of the State Grievance Review is final.

Authorized Representatives (See FAQ #17 - #19)

If you need assistance filing a grievance, please call the Medicaid Ombudsman’s Office: KOAN at 808-746-3324

IF YOU HAVE MEDICAID AND ARE DENIED A BENEFIT, DENIED PAYMENT OR COVERAGE FOR A SERVICE, OR YOUR SERVICES ARE REDUCED, you can appeal this decision by contacting your health plan: AlohaCare, HMSA, Kaiser Permanente, Ohana Health Plan. UnitedHealthcare Community Plan, Community Care Services (CCS) or Hawaii Dental Service (HDS).

What if I am not happy with my health plan’s Appeal decision?

If you are not happy with your health plan’s decision, you can request an Appeal (You can request a State level appeal)

State Administrative Appeal

To request a State Administrative Appeal, you must complete the following steps:

1. You have filed an appeal with the Health Plan.

2. You have received a Resolution of Appeal Letter from your health plan. If you do not have a Resolution of Appeal Letter, contact your health plan.

You may request a State Administrative Appeal within 120 days of the date of your Resolution of Appeal Letter.

Your request for a State Administrative Appeal can be sent in writing, email to:

In writing:

State of Hawaii Department of Human Services,

Administrative Appeals Office,

PO Box 339

Honolulu, HI 96809-0039

Email:

[email protected]

In person or by calling:

Your local Med-QUEST office.

If you need assistance filing an appeal, please call the Medicaid Ombudsman’s Office: KOAN at 808-746-3324

Authorized Representatives (See FAQ #17 - #19)

If you need assistance filing an appeal, please call the Medicaid Ombudsman’s Office: KOAN at 808-746-3324

Frequently Asked Questions

Applicants, members, and/or their authorized representatives can file a grievance when they have a complaint about anything that does not involve appealing a decision, such as a denial or discontinuance of services or benefits.

Examples

General Complaints
Environmental hazard conditions at a doctor's office (dirt or clutter, unsanitary practices, overcrowded waiting areas)
Impoliteness or rudeness of providers (doctors, doctor's office staff, hospital personnel, etc.)
Impoliteness or rudeness of office staff (eligibility offices, AHCCCS Offices, Department of Economic Security Offices, Department of Health Services Offices, etc.)

An appeal is a request from an applicant, member, provider, health plan, or other approved entity to reconsider or change a decision, also known as an action.

An action includes any denial, reduction, suspension, or termination of a service or benefit, or a failure to act in a timely manner.

Examples

Denial of request for surgery
Denial of a request for a wheelchair
Denial of basic health care services
Denial or discontinuance of AHCCCS eligibility

Member is an individual who has been approved for Medicaid and has been assigned a Health Plan.

Hyperlink Grievance Section

Hyperlink to Appeals Section

Some reasons for submitting a grievance include:

1. The quality of the care or service you received.

2. The way the health plan staff treated you.

3. How you were treated by the doctor or staff.

4. The exercise of your members rights related to your healthcare.

The time to make a prior authorization decision.

In order to request a State Grievance Review, you must complete the following steps:

1. You have filed a grievance with the Health Plan, CCS or HDS.

2. You have received a Grievance Resolution Letter. If you do not have a Grievance Resolution Letter, contact your health plan, CCS or HDS.

You may request a State Grievance Review within 30 days of the date of your Grievance Resolution Letter.

To request a State Grievance Review, call 808-692-8094, leave a message, speak slowly and clearly provide the following information:

1. Your full name

2. Your last name

3. Your phone number

4. The reason for your call

5. The date of your resolution letter

Med-QUEST will return your call within 3 business days. The outcome or resolution of the State Grievance Review is final.

a) When a Member receives a Notice of Adverse Benefit Determination, the Member first requests for an appeal with the Health Plan.

b) After a decision is made regarding the appeal, the Health Plan will send a Final Resolution letter to the Member to inform them of the appeal decision.

c) The Member will then be able to request for a State administrative hearing.

a) If the Member is not satisfied with the written notice of the final disposition of the appeal from the Health Plan, the Member may file for a State administrative hearing within one hundred and twenty (120) days.

b) If the Member is not satisfied with the decision by the hearing officer, the Member may file for an appeal with the Court.

If you need assistance filing a grievance or appeal, please call the Medicaid Ombudsman’s Office: KOAN at 808-746-3324

If you are interested in applying for Medicaid, please click this link:

https://medquest.hawaii.gov/en/members-applicants/get-started/how-to-apply.html

Med-QUEST Eligibility Branch Office at Med-QUEST Customer Service:

1-800-316-8005 toll-free. TTY users, call 1-855-889-4325 toll-free or 711.

Additional contact information for your local Med-QUEST Eligibility Branch office is available at: Contact Us

a. AlohaCare

b. HMSA

c. Kaiser Permanente

d. Ohana Health Plan

e. UnitedHealth Community Plan

Ohana Health Plan-CCS

Hawaii Dental Services ( HDS)

Yes, if they are designated to be Member’s Authorized Representative

A representative can be a relative, friend, advocate, attorney, doctor (other than your treating physician), or someone else to act on member’s behalf.

a) Member can allow another person to represent their interest during any stage of a Grievance or Appeal process.

b) Member can request to appoint an Authorized Representative, in person or by telephone in which member gives a written authorization. DHS 1121

Medicaid ask that if you have been appointed or given legal authority to represent member, then you may submit a completed DHS 1121A form, including attaching a copy of the appropriate legal document.

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