Medicare Member Appeals

You have the right to appeal any decision we’ve made about services or benefits that we denied. If you need help understanding our decision, please call us seven days a week, 8 a.m. to 8 p.m. at 948-6000 on Oahu, or 1-800-660-4672 toll-free on the Neighbor Islands and Mainland. For TTY, call 711. You can also visit your nearest HMSA Center or office and we’ll be happy to help. We’ll help you understand:

  • The rules and guidelines that we used to determine HMSA’s payment.
  • The medical explanation of why your plan didn’t pay for the service.
  • The diagnosis and treatment codes submitted for your claim and what they mean.

You can file an appeal within 60 days after the date of the denial. If you want someone else to act for you, you can name a relative, friend, attorney, doctor, or someone else to act as your representative. Both you and the person you want to act for you must sign and date a statement confirming this is what you want and mail or fax this statement to us with every appeal.

Standard appeal – Generally, we use the standard deadlines for giving you our decision. For an appeal for a medical service you haven’t yet received, we’ll give you an answer within 30 days after we receive your request. We may need more time if we need information that could benefit you. If we take extra time, we’ll tell you in writing.

For a standard appeal for prescription drugs, we’ll give you an answer within seven calendar days.

Fast appeal – If your health requires it, you can ask for a fast appeal. We’ll give you an answer within 72 hours after we receive your appeal.

Instructions

To start an appeal, you, your doctor, or your representative, must contact us. You may use the following appeal forms to mail or fax to our appeals coordinator at the address below.

To review your appeal, we’ll need the following information:

  • Your full name.
  • Your HMSA subscriber ID number.
  • A daytime telephone number.
  • The service (for example, laboratory tests, surgery, or prescription medications.)
  • Your HMSA notice of coverage or denial.
  • Provider’s name.
  • Description of the facts, including why you don’t agree with our decision.
  • Supporting documents, if any.
  • Personal Authorization to appoint someone to help you, if applicable.

Sign and date the form and mail it to:
HMSA Akamai Advantage
Attn: Appeals Coordinator
P.O. Box 1958
Honolulu, HI 96805-1958

Or fax to: 808-952-7546

For process or status questions, members and/or physicians can contact HMSA Member Advocacy & Appeals:

During business hours: Monday through Friday, 8 a.m. to 8 p.m.: 808-948-5090 on Oahu or 1-800-462-2085 toll-free on the Neighbor Islands and Mainland.

After business hours (requests for fast appeals only): 808-948-6483. This is not a Customer Relations phone number.

TTY users, call 711.