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Hawaii Care Provider Manual

Physician, Health Care Professional, Facility and Ancillary Care  |  Hawai’i QUEST Integration

 

Welcome

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. 

PARTICIPATION AGREEMENT

In this manual, we refer to your Participation Agreement as “Agreement”.

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:

  • Improve the health status of the QUEST Integration member population
  • Minimize administrative burdens, streamline access to care for members with changing health status, and improve healthcare outcomes by integrating programs and benefits
  • Align the program with the Affordable Care Act (ACA)
  • Improve care coordination by establishing a “provider/ medical home” for members through the use of assigned primary care providers (PCPs)
  • Expand access to home and community based services (HCBS) and allow members to have a choice between institutional services and HCBS
  • Maintain a managed care delivery system that assures access to high quality, cost-effective care that is provided whenever possible, in the member’s community, for all covered populations
  • Establish contractual accountability among the State, UnitedHealthcare Community Plan, and providers
  • Develop a program that is fiscally predictable, stable, and sustainable over time
  • Expand and strengthen a sense of member responsibility and promote independence and choice among members that leads to a more appropriate utilization of the health care system
  • Develop a program that places maximum emphasis on the efficacy of services and offers health plans both incentives for quality and sanctions for failure to meet measurable performance goals

Questions About Material?

If you have questions about this manual or about our policies, please call Provider Services. See How to Contact Us at bottom of page.

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Looking for a different state Community Plan (Medicaid) Care Provider Manual?

Click Here to View the Masterlist

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.

How to Contact Us

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

providerexpress.com

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

UHCprovider.com/benefits

888-980-8728

Confirm a member’s benefits and/or prior authorization.

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.

ac_edi_ops@uhc.com

800-210-8315

Ask about claims issues or questions.

800-842-1109

Information is also available at UHCprovider.com.

UHCprovider.com/eligibility

888-980-8728

Confirm member eligibility.

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.

Medicaid.gov

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.

nppes.cms.hhs.gov

800-465-3203

Apply for a National Provider Identifier (NPI).

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

Prenatal risk assessment form

Links for pregnant moms and newborn babies.

LinkSupport@optum.com

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.

UHCprovider.com/priorauth

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.

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

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.

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.