Physician, Health Care Professional, Facility and Ancillary Care | Hawai’i QUEST Integration
Welcome to the UnitedHealthcare Community Plan provider manual. This up-to-date provider manual allows you and your staff to find important information such as how to process a claim and prior authorization. This manual also includes important phone numbers and websites on the How to Contact Us page. Find operational policy changes and other electronic tools on our website at UHCprovider.com.
CLICK THE FOLLOWING LINKS TO ACCESS DIFFERENT MANUALS:
• UnitedHealthcare Administrative Guide for Commercial and Medicare Advantage member information. Some states may also have Medicare Advantage information in their Community Plan manual.
• A different Community Plan manual: go to UHCprovider.com. Click Menu on top left, select Administrative Guides and Manuals, then Community Plan Care Provider Manuals, select state.
We greatly appreciate your participation in our program and the care you offer our members.
If there is a conflict between your Agreement and this care provider manual, use this manual unless your Agreement states you should use it, instead. If there is a conflict between your Agreement, this manual and applicable federal and state statutes and regulations and/ or state contracts, applicable federal and state statutes
and regulations and/or state contracts will control. UnitedHealthcare Community Plan reserves the right to supplement this manual to help ensure its terms and conditions remain in compliance with relevant federal and state statutes and regulations. This manual will be amended as policies change.
Terms and definitions as used in this manual:
QUEST Integration is the State of Hawai’i’s managed care Medicaid program. It brings together into a single program previous Medicaid programs such as QUEST, QUEST Expanded Access (QExA), QUEST-ACE and QUEST-Net as well as Medicaid Expansion under the
Affordable Care Act (ACA). The program includes persons eligible for Medicaid and Children’s Health Insurance Program (CHIP).
The goals of the State of Hawai‘i and UnitedHealthcare Community Plan are to:
Terms and definitions as used in this manual:
If you have questions about this manual or about our policies, please call Provider Services. See How to Contact Us at bottom of page.
If you need an older version of an Administrative Guide or Care Provider Manual, please contact your Provider Advocate. To find the contact information for your Provider Advocate, go to Find a Network Contact and then select your state.
1132 Bishop St., Suite 400
Honolulu, HI 96813
NOTE: Please do not submit claims to this address. Use the claims address listed below under Claims.
888-980-8728
TTY: 711 (Hearing Impaired)
Open 7:45 a.m. to 4:30 p.m. Hawaii Standard Time (HST) Monday through Friday
888-980-8728
866-622-8054 (MA-DSNP)
Fax: 877-840-5581
Mailing Address:
Optum
P.O. Box 30757
Salt Lake City, UT 84130-0757 Payer ID: 87726
For prior authorization or a current list of CPT codes that require prior authorization, visit UHCprovider.com/hicommunityplan
Prior Authorization and Notification. 866-889-8054
Request prior authorization of the procedures and services outlined in this manual’s prior authorization requirements.
Use the Link Provider Portal at UHCprovider.com/claims
888-980-8728
Mailing address:
UnitedHealthcare Community Plan QUEST Integration
P.O. Box 31365
Salt Lake City, UT 84131-0365
Payer ID#: 87726 (EDI Claims Submission) Payer ID# 04567 (ERA use)
Ask about a claim status or about proper completion or submission of claims.
888-980-8728
Ask about behavioral claim disputes.
See the Overpayment section for requirements before sending your request.
Sign in to UHCprovider.com/claims to access Link, then select the UnitedHealthcare Online app
888-980-8728
Mailing address:
UnitedHealthcare Community Plan
ATTN: Recovery Services
P.O. Box 740804 Atlanta, GA 30374-0800
Ask about claim overpayments.
800-842-1109
Information is also available at UHCprovider.com.
800-455-4521 or 877-401-9430
Notify us of suspected fraud or abuse by a care provider or member.
Phone: 888-980-8728 (TTY users: 711)
Fax: 800-267-8328
Refer high-risk OB members. Fax initial prenatal visit form.
Department of Human Services: (Oahu)
808-524-3370
TTY/TDD #: 808-692-7182
(Neighbor Islands) 800-316-8005
TTY/TDD #: 800-603-1201
Website: medquest.hawaii.gov
Contact Medicaid directly.
Sign in to UHCprovider.com/claims to access Link, then select the UnitedHealthcare Online app
888-980-8728
Reconsiderations mailing address:
UnitedHealthcare Community Plan
P.O. Box 31350
Salt Lake City, UT 84131-0365
Appeals mailing address: Community Plan Grievances and Appeals
1132 Bishop Street Suite 400
Honolulu, HI 96813
Claim issues include overpayment, underpayment, payment denial, or an original or corrected claim determination you don’t agree with.
888-980-8728
Assist members with issues or concerns. Available 7:45 a.m. to 4:30 p.m. HST Monday through Friday.
888-980-8728 or TTY 711 for hearing impaired
Available 8 a.m. – 5 p.m. Central Time, Monday through Friday, except state-designated holidays.
888-980-8728 or TTY 711 for hearing impaired
Available 24 hours a day, seven days a week.
Hapai Malama
Phone: 888-980-8728 (TTY users: 711)
Fax: 800-267-8328
855-819-5909
Available 7 a.m. – 9 p.m. Central Time, Monday through Friday;
6 a.m. – 6 p.m. Central Time, Saturday;
and 9 a.m. – 6 p.m. Central Time, Sunday.
UHCprovider.com/hicommunityplan > Pharmacy Resources and Physician Administered Drugs
877-305-8952 (OptumRx)
800-797-9791 (Help Desk)
800-584-0265 (Bioscrip-Specialty Drug)
OptumRx oversees and manages our network pharmacies.
Use Link to access the PreCheck MyScript tool. Request prior authorization and receive results, and see which prescriptions require prior authorization or are not covered or preferred. Check coverage and price, including lower-cost alternatives.
800-310-6826
Fax: 866-940-7328
Request authorization for medications as required.
UHCprovider.com/hicommunityplan > Prior Authorization and Notification
888-980-8728
Fax: 800-267-8328
Request authorization/notify of the procedures and services outline in the prior authorization/ notification requirements section of this manual.
Complete and current list of prior authorizations.
877-842-3210 from 7 a.m. to 7 p.m. local time, Monday through Friday
The process for completing the notification/prior authorization request and time frames remains the same. You can learn more about how to use the prior authorization advanced notification (PAAN) link through training, complete the notification/prior authorization process or confirm a coverage decision
888-980-8728
For Medicare Advantage-Dual Special Needs Program (MA-DSNP):
866-622-8054
7:45 a.m. to 4:30 p.m. HST Monday through Friday
Use Link to access the PreCheck MyScript tool. Request prior authorization and receive results, and see which prescriptions require prior authorization or are not covered or preferred.
Check coverage and price, including lower-cost alternatives.
UHCprovider.com/hicommunityplan > Prior Authorization and Notification
866-889-8054
Fax: 866-889-8061
Request prior authorization of the procedures and services outlined in this manual’s prior authorization requirements.
Complete and current list of prior authorizations.
UHCprovider.com > Menu > Health Plans by State > [Select State] > “View Offered Plan Information" under the Medicaid (Community Plan) section > Bulletins and Newsletters.
Reimbursement policies that apply to UnitedHealthcare Community Plan members We encourage you to regularly visit this site to view reimbursement policy updates.
Provider Services 888-980-8728
800-784-8669
Ask about services for quitting tobacco/ smoking.
Logisticare 866-475-5744
866-288-3133 (Hearing Impaired)
Schedule transportation or for transportation assistance. To arrange non-urgent transportation, please call three days in advance.
Provider Services 888-980-8728
UM helps avoid overuse and under-use of medical services by making clinical coverage decisions based on available evidence-based guidelines.
Request a copy of our UM guidelines or information about the program.
808-586-8300
Fax: 573-526-5220
Care providers must participate in the VFC Program administered by the Department of Health and Senior Services (DHSS) and must use the free vaccine when administering vaccine to qualified eligible children. Providers must enroll as VFC providers with DHSS to bill for the administration of the vaccine.
888-980-8728
Refer high-risk members (e.g., asthma, diabetes) and members who need private-duty nursing.
UHCprovider.com/HIcommunityplan
Access your state specific community plan information.