What is prior authorization?
Prior authorization (PA) means the carrier must approve certain care before it happens. A PA denial is different from a claim denial after care was provided.
Overview for any state: Prior authorizations. This page is Hawaii-only.
Confirm plan type: Hawaii: Start Here.
Hawaii utilization review
Hawaii regulates utilization review—including prior authorization—under the Patients' Bill of Rights and Responsibilities Act (HRS Chapter 432E). Utilization review organizations must be certified; carriers must provide appeal and external review rights for adverse determinations.
Prospective (PA) review
PA is a form of prospective utilization review (HRS § 432E-1). Specific decision timeframes are often set in plan materials and federal ACA rules for Marketplace plans.
ACA & federal minimums
For non-grandfathered plans, federal rules in 45 C.F.R. § 147.136 still apply (often 15 calendar days non-urgent, 72 hours urgent).
Transparency reporting
Hawaii has added reporting requirements for utilization review entities to submit PA data to the State Health Planning and Development Agency (SHPDA) so the state can analyze approval and denial patterns—check current DCCA and SHPDA guidance for what applies to your plan year.
Where to look up PA rules
Match tools to the exact plan on the ID card:
- HMSA (Hawaii Medical Service Association): hmsa.com
- Kaiser Permanente Hawaii: kaiserpermanente.org — Hawaii
- UHA (University Health Alliance): uhahealth.com
Med-QUEST
Medicaid PA follows Med-QUEST and MCO rules—not commercial Chapter 432E alone. Service denials: MCO grievance, then DHS fair hearing—see medquest.hawaii.gov.
If PA is denied
- Get the adverse determination in writing with clinical reasons and appeal instructions.
- Ask the treating clinician for records and a medical-necessity letter.
- File an internal appeal—see Hawaii internal appeals.
- If care cannot wait, request expedited review (often 72 hours).
Building a strong appeal packet has a checklist.
Urgent care
Request expedited internal review when delay would seriously jeopardize life, health, or ability to regain functioning. You may apply for expedited external review at the same time as expedited internal appeal (HRS § 432E-33(b)(2)). See Hawaii external review.