Grievance and Appeals

A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described in the determinations and appeals section of your Evidence of Coverage. Examples of grievances include:

• You are involuntarily disenrolled from AlohaCare Advantage Plus
• Change in cost sharing from one contract year to the next
• Change in premiums from one contract year to the next
• Difficulty in reaching AlohaCare Advantage Plus on the telephone
• Difficulty in reaching your provider on the telephone
• Quality of care of services provided
• Interpersonal aspects of care
• Provider staff behavior
• Rudeness
• Failure to respect an enrollee's rights

Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling Member Services. If you wish to appoint someone to act on your behalf, you must complete an Appointment of Representative form and send it to us with your grievance.

We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest.

You may request an expedited grievance if you disagree with our decision to:

• Not grant you an expedited appeal.
• Not grant you an expedited determination.
• Extend the standard review period of an initial decision or appeal.

We will promptly acknowledge that we received your expedited or "fast grievance" within 24 hours. A resolution to your grievance will be accomplished in the timeliest manner but no more than 72 hours from the time of our receipt.

If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have.

To file a grievance or to ask process or status questions you or your representative may:

• Call 808-973-6395 or toll free at 1-866-973-6395
• TTY/TDD: 1-877-447-5990
• Fax: 1-800-830-7222
• Write: AlohaCare Advantage Plus
  Attn: Grievance & Appeals Division
  1357 Kapi`olani Blvd, Suite G101
  Honolulu, HI 96814
• File a Member Grievance Form

If we make a coverage decision and you are not satisfied with our decision or part of our decision, you or your appointed representative can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. If your health requires a quick response, you may ask for a "fast appeal."

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the benefits properly. When we have completed the review we will give you our decision in writing.

If we say no to all or part of your initial appeal, there are additional levels of appeal outside our plan. If we deny your appeal, we will inform you about pursuing your appeal further. Also, these additional levels are explained in your Evidence of Coverage in Chapter 9 (“What to do if you have a problem or complaint (coverage decisions, appeals, complaints)”).

To file an appeal or to ask process or status questions you or your representative may:

• Call 808-973-6395 or toll free at 1-866-973-6395
• TTY/TDD: 1-877-447-5990
• Fax: 808-973-2140
• Write: AlohaCare 
  Attn: Grievance & Appeals Division
  1357 Kapi`olani Blvd, Suite G101
  Honolulu, HI 96814

Expedited Appeals

You can call us at our toll-free phone: 1-866-973-6395 and ask for an expedited appeal.

For an after-hours expedited appeals request you can call us at 808-356-5959.

If we decide that you do need an expedited appeal, we will make a decision and give you an answer within 72 hours. We will also call you with our decision and then will send you a letter with our decision in writing.

If we think that we need more information in order to do a more complete review, we will ask you if we can take more time (up to 14 days). We will let you know of any extension verbally and in writing. If you do not agree with the extension, we will make a decision within 72 hours using the information currently available.