New to helping someone in Hawaii?
Start with three things from the patient or family:
- Insurance card — shows the carrier and plan name
- Denial letter or explanation of benefits (EOB) — lists appeal rights and deadlines
- Summary of Benefits and Coverage (SBC) — if available
Your first job is to learn what kind of plan this is (Marketplace, job-based, Medicaid, Medicare) and what deadline the letter gives you. Hawaii uses terms like adverse determination and external review through the Insurance Division.
For steps that work in every state, use these general guides first, then return here for Hawaii rules:
What is different in Hawaii?
- HealthCare.gov partnership: Individual Marketplace enrollment is through HealthCare.gov; HMSA, Kaiser, and other issuers serve the Hawaii market.
- Patients' Bill of Rights (HRS Ch. 432E): Utilization review, internal appeals, and binding external review by certified IROs (HRS Chapter 432E).
- External review filing: Request with the Insurance Commissioner within 130 days of the final internal denial; $15 filing fee (refunded if you win) (HRS § 432E-33).
- Internal appeals: Often up to 60 days standard; 72 hours expedited when delay would seriously jeopardize health (coveragerights.org — Hawaii).
- Medicaid (Med-QUEST): MCO appeal, then DHS fair hearing—different from commercial 432E rules.
Who is in charge of your plan?
- Hawaii Insurance Division (DCCA): Fully insured health plans, external review, complaints — cca.hawaii.gov/ins.
- U.S. Department of Labor: Many self-funded employer plans.
- Hawaii DHS / Med-QUEST: Medicaid fair hearings — medquest.hawaii.gov.
- CMS: Medicare and Medicare Advantage.
For complaints after appeals, see Regulator complaints.