Provider Grievance and Appeals

Grievance - A written communication made by a provider expressing dissatisfaction pertaining to the following:

• Benefits and limits, for example, limits on behavioral health services or formulary;
• Eligibility and enrollment, for example, long wait times or inability to confirm enrollment or identify the PCP;
• Member issues, including members who fail to meet appointments or do not call for cancellations, instances in which the interaction with the member is not satisfactory; instances in which the member is rude or unfriendly; or other member-related concerns;
• Health plan issues, including difficulty contacting the health plan or its subcontractors due to long wait times, busy lines, etc.; problems with the health plan’s staff behavior; delays in claims payments; denial of claims; claims not paid correctly; or other health plan issues.
• Issues related to availability of health services from the health plan to a member, for example, delays in obtaining or inability to obtain emergent/urgent services, medications, specialty care, ancillary services such as transportation, medical supplies, etc.;
• Issues related to the delivery of health services, for example, medication was not provided by a pharmacy, the member did not receive services the provider believed were needed, provider is unable to treat member appropriately because the member is verbally abusive or threatens physical behavior; and
• Issues related to the quality of service, for example, the provider reports that another provider did not appropriately evaluate, diagnose, prescribe or treat the member, the provider reports that another provider has issues with cleanliness of office, instruments, or other aseptic technique was used, the provider reports that another provider did not render services or items which the member needed, or the provider reports that the plan’s specialty network cannot provide adequate care for a member.

Appeal – A written request made by a provider for review of an adverse decision of a grievance.

How to File a Grievance or Appeal

Submit a written Grievance or Appeal along with any supporting documentation to:

AlohaCare

Attention: Grievance Coordinator

1357 Kapi`olani Blvd., Suite G101

Honolulu, HI 96814

Fax: (808) 973-2140

Grievances or appeals must be filed within one year from the date of the occurrence generating the grievance or appeal.

Upon receipt of the grievance or appeal, written notification of receipt will be sent to the provider within ten (10) calendar days.

AlohaCare will render a decision and notify the provider in writing within sixty (60) days of receipt of the grievance or appeal.