QUEST Integration Member Grievances and Appeals

If you have questions, suggestions, or a grievance about HMSA QUEST Integration services, we can help you with most of your questions over the phone. Please call us or send your inquiries in writing.

Sometimes, you may tell us that you’re not happy with our responses to your questions. We’ll tell you, an authorized representative, or a provider who’s acting on your behalf with your consent of your grievance and appeal rights. Call us and we can guide you through the process. Our staff can even help you file a grievance or an appeal by working with you to write a summary.

There are times when you may want your doctor or someone else to represent you. You can call and tell us who it is, but to help us know that we have the right person, be prepared to give your consent in writing.

For members whose first language isn’t English, we’ll give the answers in your native language either through a written translation or an oral interpretation. For those who are hearing impaired and are TTY users, call 1-877-447-5990 toll-free for help.

Your grievance or appeal will be reviewed by someone who hasn’t been involved in deciding anything about your case earlier.

For an appeal that deals with clinical services, such as medical, behavioral health, and long-term services, or an administrative denial for children under age 21, a health plan medical director will be the reviewer. This is especially so for any of the following:

  • A grievance or appeal that deals with clinical issues.
  • An appeal that approves a service that’s less than the service requested.
  • A grievance that deals with a review of an expedited appeal.
  • An appeal of a denial due to lack of medical necessity.

All administrative denials for children under age 21 will be reviewed and approved by the medical director.

Grievances

When to File

You may file a grievance if you’re not happy with:

  • The quality of the care or service provided.
  • The way our staff treated you.
  • Your doctor and how you were treated by the doctor or the staff.
  • The way your rights weren’t respected.

Who Can File

You, a person you choose, or your doctor can file a grievance either verbally or in writing. We need your verbal consent before we can interact with your authorized representative or your doctor. You or your authorized representative must give us written consent before a doctor can file a grievance on your behalf.

We Can Help You Write Your Grievance

If you need help writing a grievance, we can help. Our grievance coordinator can write a summary of your grievance and get your consent when you want someone else to represent you. We can also get interpreter services if you don’t speak English. If you’re hearing impaired and a TTY user, call 1-877-447-5990 toll-free.

The grievance must include:

  • Your name, address, phone number, and HMSA membership number.
  • The date of the grievance.
  • An account of the facts to support the grievance.
  • Copies of any related records or papers. Keep a copy of what you send to us for your records. We won’t return the packet to you.

Timeframe for Our Response

You can submit your grievance at any time. There’s no time limit.

We have five business days from the date we receive your grievance to let you know that we received it.

We have 30 calendar days from the date we received your grievance to give you our decision. We’ll tell you in writing the results of the decision and the date of the decision.

Grievance Decision

Once we decide, we’ll tell you in writing. It will include our decision and the date of the decision. We’ll also explain the reason for our decision and we’ll tell you about your right to file a grievance review with DHS. Our decision is final unless you choose to file a grievance review.

When You Disagree – Asking for a Grievance Review

When to File

If you’re not happy with our grievance decision, you can ask for a grievance review from DHS, Med-QUEST Division.

How to File

  • To file your grievance review by phone, call DHS, Med-QUEST Division, at 692-8094 on Oahu.
  • To submit a written review, write to the DHS, Med-QUEST Division, at:

Med-QUEST Division
Health Care Services Branch
P.O. Box 700190
Kapolei, HI 96709-0190
Phone: 692-8094

Timeframe

You have 30 days from the date you receive our decision to ask for a grievance review.

Grievance Review Decision

The DHS, Med-QUEST Division, will respond within 90 days after receiving your grievance review request. The grievance review decision made by the DHS, Med-QUEST Division, is final.

Appeals

When to File

You may file an appeal with us when one of the following actions has occurred:

  • The service you asked for was denied or restricted.
  • The authorization for a service was terminated, suspended, or reduced.
  • You aren’t happy with your health care services because they weren’t timely, there were unreasonable delays, or the grievance or appeal decision wasn’t carried out in a timely way.
  • You don’t agree with a payment that was denied or reduced.

Who Can File

You, your authorized representative, or your doctor can file an appeal either verbally or in writing. We need your verbal consent before we can interact with your doctor or authorized representative. You or your authorized representative must give us written consent before a doctor can file an appeal on your behalf. When someone requests an appeal for you, they’re called an “authorized representative.” To have an authorized representative, you must file a form with us with the person’s name. Call us to request the form and/or if you need help writing the appeal.

The appeal request must include:

  • Your name, address, phone number, and HMSA membership number.
  • The date of the appeal.
  • An account of the facts to support the appeal and why you don’t agree with our decision.
  • Copies of any related records or papers. Keep a copy of what you send to us for your records. We won’t return the packet to you.

You have the right to ask to review your case file, including medical records and any other documents that are part of your appeal.

We Can Help You Write Your Appeal

Appeals that are called in must be followed by a request in writing with your signature. If you need help writing an appeal, we can help. Our grievance coordinator can write a summary of your appeal and get your verbal consent when you want someone else to represent you. We can also get interpreter services if you don’t speak English. If you’re hearing impaired and a TTY user, call 1-877-447-5990 toll-free.

Timeframe for Our Response

You have 30 days after an action occurs to file an appeal.

We have five business days from the date we receive your appeal to let you know that we received it.

We have 30 calendar days from the date we receive your appeal to give you our decision. We may give you a response sooner if your health condition requires a quick response.

If we need more time to make our decision, we’ll let you know why in writing and what additional information is required.

If this happens, we’ll add up to 14 more calendar days to our response time. You can also request an extension.

We may give you a response sooner if your health condition requires a quick response. We’ll tell you in writing the results of the decision and the date of the decision.

Appeal Decision

Once we decide, we’ll tell you in writing. It will include our decision and the date of the decision. We’ll also explain the reason for our decision and we’ll tell you about your right to request a state administrative hearing and what steps you need to take.

Mail or Fax Written Grievances or Appeals

For written grievances or appeals, mail or fax us the information.

Mail:

HMSA QUEST Integration
P.O. Box 860
Honolulu, HI 96808-0860
Attn: QUEST Integration Grievance Coordinator

Fax: 948-8224 or 1-800-960-4672 toll-free

Phone Number

For grievances or appeals over the phone, contact the grievance coordinator. The phone number is:

Expedited Appeals

When to File

You may file an expedited appeal if the standard appeal timeline:

  • Could seriously jeopardize your life or health,
  • Could seriously jeopardize your ability to attain, maintain, or regain maximum function, or
  • Could subject you to severe pain that can’t be managed without the care or treatment that’s being requested.
We’ll let DHS know within 24 hours after we receive your request that you’ve filed an expedited appeal.

Who Can File

You, your authorized representative, or your doctor can file an expedited appeal either verbally or in writing. We need your verbal consent before we can interact with your doctor or authorized representative. You must give us written consent before your authorized representative or doctor can file an expedited appeal on your behalf. When someone requests an expedited appeal for you, they are called an “authorized representative.” To have an authorized representative, you must file a form with us with the person’s name. Call us to request the form and/or if you need help writing the expedited appeal.

No punitive action will be taken against a provider who requests an expedited appeal or who supports a member who files an expedited appeal.

The expedited appeal request must include all of the following:

  • Your name, address, phone number, and HMSA membership number.
  • The date of the expedited appeal. For requests received over the phone, the date of the call will be the date of the inquiry.
  • An account of the facts to support the expedited appeal.
  • Copies of any related records or papers. Keep a copy of what you send to us for your records. We won’t return the packet to you.
  • Please use the mail, fax, or phone information noted earlier in this chapter to file your expedited appeal request.

We Can Help You Write Your Expedited Appeal

If you need help writing an expedited appeal, we can help. Our grievance coordinator can write a summary of your expedited appeal and get your consent when you want someone else to represent you. We can also get interpreter services if you don’t speak English. If you’re hearing impaired and a TTY user, call 1-877-447-5990 toll-free. A written appeal request isn’t required when an oral request has been made.

Timeframe for Our Response

You have 30 calendar days from the date of your denial letter to file an expedited appeal.

We have no more than three business days from the date we receive your expedited appeal request to give you our decision.

If we need more time to make our decision, we’ll let you know why in writing and what additional information is required. We’ll report our request for an extension to DHS and show how this delay will be in your best interest. If this happens, we’ll add up to 14 more calendar days to our response time. We may give you a response sooner if your health condition requires a quick response. You may also send us a request for an extension.

Denial of Expedited Appeal Request

If you asked for an expedited appeal but we decide that one isn’t needed, we’ll call and also inform you in writing. The information we share will include that your appeal is being reviewed as a standard appeal and we’ll tell you how to file a grievance if you’re not happy with our decision.

Expedited Appeal Decision

Within three business days from the time we receive your request, we’ll tell you in writing the results of the decision and the date of the decision. We’ll make every reasonable effort to tell you our decision by phone, followed by a written notice within two days from the date of the decision.

For decisions that aren’t all in your favor, the notice will explain your rights to request:

  • A state administrative hearing and instructions on how to file an appeal.
  • An expedited state administrative hearing and instructions on how to file an appeal.
  • To continue benefits while the hearing is pending and how to make this request. You will also be told that you may be held liable for the cost of benefits paid during the hearing if the state’s decision isn’t in your favor.

DHS State Administrative Hearing

You can ask for a state administrative hearing if you’re not happy with our appeal decision. The appeal must be in writing. You must submit the appeal to the DHS Administrative Appeals Office within 30 days from the time you received our appeal decision.

Mail the appeal to:

State of Hawaii Department of Human Services
Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809-0039

DHS will make its decision within 90 days from the date the request was filed. The DHS administrative hearing decision will prevail and be in effect.

Expedited DHS Administrative Hearing

You may file for an expedited hearing with DHS only when we deny your expedited appeal. You must send a letter to DHS within 30 days from the date you received our decision.

Send the letter to:

State of Hawaii Department of Human Services
Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809-0339

DHS will decide on your request within three business days after you filed your request. DHS won’t extend this deadline. We’ll send DHS the information that was used to make our decision within 24 hours from the time of the denial.

Continuation of Benefits

You have the right to request that we continue to pay for covered services when:

  • You filed your appeal or expedited appeal within 10 days from the mail date of the denial or before the effective date of the proposed adverse action.
  • The appeal or expedited appeal is in regard to ending, suspending, or reducing treatment that had been approved before.
  • The services were ordered by the authorized provider and the original authorization period hasn’t ended.

To request to continue coverage while the appeal is being decided, contact us. If the appeal or expedited appeal decision is upheld, you may have to pay us back for the services you received during the review period.

Medicaid Ombudsman Program

The state of Hawaii’s Department of Human Services has the Medicaid ombudsman program to help you with any problems with QUEST Integration.

The Medicaid ombudsman phone numbers are: