Hawaii Care Provider Manual

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

Terms and definitions as used in this manual:

• “Member” or “customer” refers to a person eligible and enrolled to receive coverage from a payer for covered services as defined or referenced in your Agreement.
• “You,” “your” or “provider” refers to any health care provider subject to this manual, including physicians, health care professionals, facilities and ancillary providers; except when indicated and all items are applicable to all types of health care providers subject to this guide.
• Community Plan refers to UnitedHealthcare's Medicaid plan
• “Your Agreement,” “Provider Agreement” or “Agreement” refers to your Participation Agreement with us.
• “Us,” “we” or “our” refers to UnitedHealthcare Community Plan on behalf of itself and its other affiliates for those products and services subject to this guide.
• Any reference to “ID card” includes both a physical or digital card.

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.

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/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.

UHCprovider.com/priorauth

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

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.