FAQ's Regarding External Reviews

What is an External Review?

An external review is the process by which an independent review is made of a decision made by the enrollee’s managed care plan.

Under the Hawaii Revised Statutes, Section 432E-6, after exhausting all internal appeal procedures available for the managed care plan, enrollees have the option of requesting an external review.

A written request for external review must be received by the Insurance Commissioners Office within 60 days from the date of the managed care plan’s final internal determination. This request may be filed by the enrollee, the enrollee’s treating provider, or appointed representative.

Upon a showing of good cause, the commissioner may appoint a three-member panel to hear the case. The panel is made up of a provider licensed to practice and practicing medicine in Hawaii and not involved in the complaint, a representative from a managed care plan not involved in the complaint, and the Insurance Commissioner or the commissioner’s designee. If the amount in controversy is less than $500, the commissioner may conduct a review hearing without appointing a review panel. The hearing must be held within 60 days of the request for the external review, unless this deadline is waived by the parties.

The Insurance Commissioner, upon a majority vote of the panel, shall issue an order affirming, modifying or reversing the managed care plan’s final internal determination within thirty days of the hearing.

This process does not apply to claims or allegations of health provider malpractice, professional negligence, or other professional fault against participating providers.

What is an Expedited Review?

Under Hawaii Revised Statutes, Section 432E-6.5, Expedited Reviews may be authorized if it is determined that the standard review time frame may:

• Seriously jeopardize the life or health of the enrollee;
• Seriously jeopardize the enrollee’s ability to gain maximum functioning; or
• Subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the expedited review.

An external review conducted as an expedited review shall be decided no later than seventy-two hours after receipt of the request for external review.

Who do I submit my request to?

Department of Commerce and Consumer Affairs
Insurance Division
Health Insurance Branch
P.O. Box 3614
Honolulu, Hawaii 96811
(808) 586-2804
Fax: (808) 587-5379