(a) An enrollee may request that the internal appeal under § 432E-5 be conducted as an expedited appeal. If a request for expedited appeal is approved by the health carrier, the appropriate internal appeal shall be completed within seventy-two hours of receipt of the request for expedited appeal.

Terms Used In Hawaii Revised Statutes 432E-6.5

  • Appeal: means a request from an enrollee to change a previous decision made by the health carrier. See Hawaii Revised Statutes 432E-1
  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Enrollee: means a person who enters into a contractual relationship under or who is provided with health care services or benefits through a health benefit plan. See Hawaii Revised Statutes 432E-1
  • Health carrier: means an entity subject to the insurance laws and rules of this State, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a mutual benefit society, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits or health care services. See Hawaii Revised Statutes 432E-1
  • Managed care plan: means any plan, policy, contract, certificate, or agreement, regardless of form, offered or administered by any person or entity, including but not limited to an insurer governed by chapter 431, a mutual benefit society governed by chapter 432, a health maintenance organization governed by chapter 432D, a preferred provider organization, a point of service organization, a health insurance issuer, a fiscal intermediary, a payor, a prepaid health care plan, and any other mixed model, that provides for the financing or delivery of health care services or benefits to enrollees through:

    (1) Arrangements with selected providers or provider networks to furnish health care services or benefits; and

    (2) Financial incentives for enrollees to use participating providers and procedures provided by a plan;

    provided that for the purposes of this chapter, an employee benefit plan shall not be deemed a managed care plan with respect to any provision of this chapter or to any requirement or rule imposed or permitted by this chapter that is superseded or preempted by federal law. See Hawaii Revised Statutes 432E-1

  • provider: means a health care professional. See Hawaii Revised Statutes 432E-1
(b) An expedited appeal shall be authorized if the application of the sixty day standard review time frame may:

(1) Seriously jeopardize the life or health of the enrollee;
(2) Seriously jeopardize the enrollee’s ability to gain maximum functioning; or
(3) Subject the enrollee to severe pain that cannot be adequately managed without the care or treatment that is the subject of the expedited appeal.
(c) The decision as to whether an enrollee’s complaint is an expedited appeal shall be made by applying the standard of a reasonable individual who is not a trained health professional. The decision may be made for the managed care plan by an individual acting on behalf of the managed care plan. If a licensed health care provider with knowledge of a claimant’s medical condition requests an expedited appeal on behalf of an enrollee, the request shall be treated as an expedited appeal.

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