Grievance and Appeal

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.

Phone:	HOLDER
Fax:	HOLDER
Mailing Address:	HOLDER

Forms

FAQs

KOLEA