Hawaii External Review

What is external review?

Hawaii external review is an independent review of a carrier's adverse determination by a certified independent review organization (IRO) under HRS Chapter 432E, Part IV (§§ 432E-31–432E-44).

IRO decisions are generally binding on the health carrier (HRS § 432E-37).

Start with Hawaii internal appeals. Background: Appeals roadmap.

When you can use it

Eligible disputes often include:

• Medical necessity, appropriateness, setting, level of care, or effectiveness
• Experimental or investigational treatment (special procedures under § 432E-36)
• Rescission of coverage in some cases

You can generally request external review when:

• You completed internal appeals and received a final adverse determination, or
• The carrier waived exhaustion, substantially failed internal procedures, or you filed concurrent expedited appeals (HRS § 432E-33(b))

File within 130 days of the final internal determination (coveragerights.org — Hawaii).

How to request it (step by step)

1. Complete internal appeal unless an exception in § 432E-33(b) applies.
2. Request forms from your carrier: final determination letter, medical records release, conflict-of-interest disclosure (DCCA — external review FAQs).
3. Prepare a cover letter explaining why coverage should be provided and whether you need standard or expedited review.
4. Pay the $15 filing fee(check payable to "Department of Commerce and Consumer Affairs")—refunded if the denial is reversed; hardship waiver available (HRS § 432E-33(a)(4)).
5. Submit in writing to the Insurance Commissioner with all attachments. Contact the Insurance Division for current mailing address (cca.hawaii.gov/ins).
6. Commissioner assigns an IRO; receive binding written decision.

How long it takes

• Standard external review: generally no more than 45 days after the request is received (HRS § 432E-34; coveragerights.org — Hawaii)
• Expedited: generally within 72 hours (HRS § 432E-35)
• Experimental/investigational (standard): up to 20 days for IRO clinical opinion (HRS § 432E-36)

When it does not apply

• Self-funded ERISA plans (carrier acts only as administrator)
• Medicare / Medicare Advantage
• Medicaid / Med-QUEST — MCO grievance and DHS fair hearing

Urgent cases

You may apply for expedited external review at the same time you apply for expedited internal appeal if you are eligible (HRS § 432E-33(b)(2)). Oral notice may be followed by written confirmation within 48 hours per carrier/IRO procedures.

See Hawaii prior authorization law and expedited appeals.