FAQs Claim Reconsideration and Appeal

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FAQs - Claim Reconsideration and Appeal

A. Refer to the diagram below. Please contact Customer Services if you need further assistance.

A. Yes, claims can be reconsidered for a variety of reasons. Please contact Customer Services for assistance.

A. If you are not satisfied with our response to your concern, you may file a formal appeal. The appeal must be filed within one year of the date UHA informed you of the denial you wish to appeal. Appeals must be submitted in writing to:

UHA Appeals Coordinator
700 Bishop Street, Suite 300
Honolulu, HI 96813

Your appeal will be reviewed by staff not involved in the original decision (nor a subordinate to the original decision maker). If the appeal concerns a clinical matter, it will be reviewed by an independent licensed practitioner with appropriate expertise and experience. If we need additional information to complete our review, we will notify you and give you reasonable time to respond.

For more information, please view our Provider Handbook.

The final decision will be made by the UHA Appeals Committee. You will be notified of the final decision within 60 days of receipt of your written appeal, or within 30 days if your appeal concerns a denial of a clinical matter.

Expedited Appeals

You can request an Expedited Appeal (72-hour response time for UHA's final internal determination) if the standard time (30 or 60 days, as set forth above) for completing an appeal would:

  • seriously jeopardize the members life or health;
  • seriously jeopardize the members ability to gain maximum functioning; or
  • subject the member to severe pain that cannot be adequately managed without the care or treatment requested.

Expedited appeals are only appropriate when a denial affects care that is in progress or to be initiated.  Expedited appeals do not apply to payment denials for services already rendered.

To request an Expedited Appeal, call Health Care Services.  All necessary information regarding such appeal may be submitted by facsimile, or other expeditious means.

A. If you wish to contest our decision on any appeal, you must agree to binding arbitration. To request binding arbitration, you must submit a written request for arbitration to UHA within 60 days of the date of the letter communicating the decision of the Appeals Committee. Both parties will agree on the person to serve as the independent arbitrator. The decision of the arbitrator is binding on both parties. Costs for the arbitration will be shared as ordered by the arbitrator. Further details are provided in your Participating Provider Agreement.