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Grievance, Appeals & Discrimination Complaints


What is a grievance?
A grievance is when you are not happy with AlohaCare or an AlohaCare provider.  Examples of something you might not be happy about are:
  • How AlohaCare or your provider runs their office
  • Things AlohaCare or your provider does
  • How AlohaCare or your provider behaved
  • If AlohaCare denied your request to make a fast decision on your appeal and takes the standard amount of time to decide
  • Issues with the quality of service or care
  • If AlohaCare or your provider did not respect your rights
  • If AlohaCare or your provider was rude
  • If AlohaCare or your provider did not keep your information private
 
What should I do if I have a grievance?
You can file a grievance report by writing or calling AlohaCare at 973-0712 (Oahu) or toll-free at 1-877-973-0712.  TTY users call 1-877-447-5990.  If you file a grievance, it will not affect the way we treat you as a member.
 
Your doctor or another person can also file a grievance for you, if you authorize them to do so.  You must tell us that you agree to have someone else talk to us about your grievance. Fill out the Appointment of Representative form to give someone permission to act on your behalf to file a grievance.  He or she may file the grievance by calling us or writing us a letter.
 
How do I file a grievance?
AlohaCare can help you file a grievance.  If you need help, call us and we can write your grievance for you.  If you need language assistance to file a grievance we will arrange that for you.  You can also write a letter to AlohaCare.  Make sure you include:
  • Your name, address, phone number, AlohaCare member ID number and signature
  • What you are unhappy about
  • Copies of any papers that have to do with the problem
  • Appointment of Representative: This form gives permission for a person to act on your behalf to file a grievance, appeal or coverage determination for you. 
  • Member Grievance Form: Let us know if you are unhappy with the services you receive from AlohaCare or your doctor.  

Call or send your letter to:

 
AlohaCare
Attn: Grievance Coordinator
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814
 
Phone: 973-0712
Toll-free: 1-877-973-0712
TTY: 1-877-447-5990
 
What is an appeal?
An appeal is action you can take if you are not happy or do not agree with a decision we have made. This includes AlohaCare’s timeliness and/or decision about health care services you are getting.  You may appeal a decision that adversely affects coverage, benefits or your relationship with AlohaCare. If you file an appeal, it will not affect the way we treat you as a member.  Examples of reasons for which an appeal can be filed are listed below:  
  • If AlohaCare denies or limits care that you or your doctor asks us to approve
  • If AlohaCare reduces, delays or stops care we already approved
  • If AlohaCare does not pay your doctor or other provider(s) for your care
  • If AlohaCare does not get you care as quickly as you think we need to
  • If AlohaCare delays getting you care you need
  • If AlohaCare does not give you a timely answer to a grievance or an appeal you already filed
  • If you live in a rural area or in an area with limited doctors, and AlohaCare does not agree to let you see a doctor not on our list
 
When do I file an appeal?
We must receive your appeal within 30 days of when AlohaCare made the decision you do not agree with.  Your doctor or another person can also file an appeal for you if you authorize them to do so.  You must tell us that you agree to have someone else talk to us about your appeal.  Fill out the Appointment of Representative form to give someone permission to act on your behalf to file a grievance, appeal or coverage determination for you.
 
 
How do I file an appeal?
AlohaCare can help you file an appeal.  If you need help, call us and we can write your appeal for you.  You can also write a letter to AlohaCare.  Make sure you include:
  • Your name, address, phone number, AlohaCare member ID number and signature
  • What you disagree with and why
  • Copies of any papers that have to do with the appeal
 
Call or send your letter to:
AlohaCare
Attn: Grievance Coordinator
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814
 
Phone: 973-0712
Toll-free: 1-877-973-0712
TTY: 1-877-447-5990
 
What if I am not happy with the results of the appeal?
If you are not happy with our response to your appeal, you can ask for a State administrative hearing. You cannot ask for a State administrative hearing if you did not send your appeal to AlohaCare first and received an answer from us. . You must write to the DHS Administrative Appeals Office within 30 days from the date of our decision.
 
You have the right to have representation at the hearing.  You can speak for yourself at the hearing.  Or, you can have a lawyer, friend, relative or someone else explain why you are not satisfied with the resolution of your appeal.
 
How do I request a State administrative hearing?
You can write a letter to:
 
State of Hawaii Department of Human Services
Attn: Administrative Appeals Office
P.O. Box 339
Honolulu, HI 96809
 
You can request an expedited State administrative hearing.  The State will respond within three business days of your request.

Nondiscrimination
It is AlohaCare’s policy not to discriminate on the basis of race, color, national origin, sex, age or disability. AlohaCare has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities. Section 1557 and its implementing regulations may be examined by contacting AlohaCare’s Compliance Officer, who has been designated to coordinate AlohaCare’s efforts to comply with Section 1557.
 
AlohaCare
Attn: Compliance Officer
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814
 
Phone: 973-0712
Toll-free: 1-877-973-0712
TTY: 1-877-447-5990
 
Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for AlohaCare to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance.
 
Procedure:
  • Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action.
  • A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
  • The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain AlohaCare’s files and records relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.
  • The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.
  • The person filing the grievance may appeal the decision of the Section 1557 Coordinator by writing to AlohaCare’s Chief Executive Officer within 15 days of receiving the Section 1557 Coordinator's decision. The Chief Executive Officer shall issue a written decision in response to the appeal no later than 30 days after its filing.

The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is available at:
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail at:
U.S. Department of Health and Human Services,
200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201.

Complaint forms are available at:
http://www.hhs.gov/ocr/office/file/index.html. Such complaints must be filed within 180 days of the date of the alleged discrimination.
AlohaCare will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings.