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Chapter 3: Care Provider Office Procedures

Once a member is assigned a PCP, view the panel rosters electronically on the UHCprovider.com application on Link. The portal requires a unique user name and password combination to gain access.

Each month, PCP panel size is monitored by reviewing PCP to member ratio reports. When a PCP’s panel approaches the max limit, it is removed from auto- assignment. UnitedHealthcare Community Plan monitors PCP panel status.

Sign in to UHCprovider.com > select Link > select the UnitedHealthcare Online application on Link > select Reports from the Tools & Resources. From the Report Search page, select the Report Type (PCP Panel Roster) from the pull-down menu > complete additional fields as required > click on the available report you want to view.

Members may have to share in the cost of their health care services. This is based on Medicaid financial eligibility. The member’s Share of Cost (SOC) amount is determined by the member’s State of Hawai‘i Medicaid eligibility worker. Members must pay that amount to one of their providers (e.g., foster care home, nursing facility or a home and community-based provider such as a home health agency) or UnitedHealthcare Community Plan every month. Members are notified of their SOC amount or responsibility and any changes via mail by his or her State of Hawaii Medicaid eligibility worker.

Each enrolled UnitedHealthcare Community Plan member either chooses or is assigned a PCP. The assignment considers the distance to the PCP, the PCP’s capacity and if the PCP is accepting new members. UnitedHealthcare Community Plan will assign members to the closest and appropriate PCP.

Depending on the member’s age, medical condition and location, the choice of PCP may cover a variety of practice areas, such as family practice, general practice, internal medicine, pediatrics and obstetrics. If the member changes the initial PCP assignment, the effective date will be the day the member requested the change. If a member asks UnitedHealthcare Community Plan to change the PCP at any other time, the change will be effective on the request date.

Deductibles and copayments are waived for covered services. See here for details.

UnitedHealthcare Community Plan only pays for medically necessary services.

Medically Necessary Definition

Medically necessary health care services or supplies are medically appropriate and:

  • Necessary to meet members’ basic health needs.
  • Cost-efficient and appropriate for the covered services.

Assignment to Unitedhealthcare Community Plan

Hawaii DHS assigns eligible members to UnitedHealthcare Community Plan daily. We manage the member’s care on the date the member is enrolled until the member is disenrolled from UnitedHealthcare Community Plan. Hawaii DHS makes disenrollment decisions, not UnitedHealthcare Community Plan.

Disenrollment usually takes effect at month’s end, but at times may occur mid-month.

At enrollment time, each member receives a welcome packet that includes a copy of the UnitedHealthcare Community Plan Member Handbook. The handbook explains the member’s health care rights and responsibilities through UnitedHealthcare Community Plan.

Obtain copies of the Member Handbook online at UHCCommunityPlan.com or contact UnitedHealthcare Provider Services.

Immediate Enrollment Changes

Immediate enrollment into managed care means the responsible payer for members, including newborns, may change from Fee for Service (FFS) to Medicaid Managed Care during hospitalization. To avoid delays in claims processing and payment, have the payer assignment of newborns checked daily.

Get eligibility information by calling the Medicaid Inquiry line.

Unborn Enrollment Changes

Encourage your members to notify the Hawaii DHS when they know they are expecting. DHS notifies Managed Care Organizations (MCOs) daily of an unborn when Hawaii Medicaid learns a woman associated with the MCO is expecting. The MCO or you may use the online change report through the Hawaii website to report the baby’s birth. With that information, DHS verifies the birth through the mother. The MCO and/or the care provider’s information is taken as a lead. To help speed up the process, the mother should notify DHS when the baby is born.

Members may call Hawaii Department of Human Services: (Oahu)

#: 808-524-3370

TTY/TDD #: 808-692-7182 (Neighbor Islands)

Toll-Free #: 800-316-8005

TTY/TDD #: 800-603-1201

Newborns may get UnitedHealthcare Community Plan- covered health services beginning on their date of birth. Check eligibility daily until the mother has enrolled her baby in a managed care plan.

PCP Selection

Although unborn children cannot be enrolled with an MCO until birth, ask your members to select and contact a PCP for their baby prior to delivery. This will help avoid the delays and confusion that can occur with deferred PCP selections.

UnitedHealthcare Community Plan members can go to myuhc.com/communityplan to look up a care provider.

UnitedHealthcare Community Plan serves members enrolled with Hawaii DHS, Hawaii’s Medicaid program. The Hawaii DHS determines program eligibility. An individual who becomes eligible for the Hawaii DHS program either chooses or is assigned to one of the Hawaii DHS-contracted health plans.

Check the member’s ID card at each visit, and copy both sides for your files. Verify the identity of the person presenting the ID card against some form of photo ID, such as a driver’s license, if this is your office practice.

If a fraud, waste and abuse event arises from a care provider or a member, notify UnitedHealthcare Community Plan in writing, as discussed in Chapter 12 of this manual. Or you may call the Fraud, Waste, and Abuse Hotline.

The member’s ID card also shows the PCP assignment on the front of the card. If a member does not bring their card, call Provider Services. Also document the call in the member’s chart.

Member Identification Numbers

The Member ID printed on the UnitedHealthcare Community Plan Member Card is the same number that Hawaii DHS issues.

A PCP may transfer a UnitedHealthcare Community Plan member due to an inability to start or maintain a professional relationship or if the member is non-compliant. The PCP must provide care for the member until a transfer is complete.

  1. To transfer the member, contact UnitedHealthcare Community Plan by mail with the specific events documentation. Documentation includes the dates of failed appointments or a detailed account of reasons for termination request, member name, date of birth, Medicaid number, current address, current phone number and the care provider’s name
    • Mailing address:
    • UnitedHealthcare Community Plan
    • Attn: Health Services
    • 1132 Bishop Street, Suite 400
    • Honolulu, HI 96813
  2. UnitedHealthcare Community Plan prepares a summary within 10 business days of the request. We try to contact the member and resolve the issue to develop a satisfactory PCP-member relationship.
  3. If the member and UnitedHealthcare Community Plan cannot resolve the PCP member issue, we work with the member to find another PCP. We refer the member to care management, if necessary.
  4. If UnitedHealthcare Community Plan cannot reach the member by phone, the health plan sends a letter (and a copy to the PCP) stating they have five business days to contact us to select a new PCP. If they do not choose a PCP, we will choose one for them. A new ID card will be sent to the member with the new PCP information.

Verify member eligibility prior to providing services. Determine eligibility in the following ways:

For information about UnitedHealthcare Dual Complete, please see Chapter 4 of the Administrative Guide for Commercial, Medicare Advantage and DSNP. For state- specific information, go to UHCprovider.com > Menu > Health Plans by State.