Medical management improves the quality and outcome of healthcare delivery. We offer the following services as part of our medical management process.
Click below to view member benefit coverage information.
Air ambulance is covered only when the services are medically necessary and transportation by ground ambulance is not available. It is also only covered when:
- Great distances or other obstacles keep members from reaching the destination.
- Immediate admission is essential or
- The pickup point is inaccessible by land.
Emergency Ambulance Transportation
An emergency is a serious, sudden medical or behavioral condition that may include severe pain. Without immediate attention, the affected person could suffer major:
- Injury to their overall health.
- Impairment to bodily functions. Or
- Dysfunction of a bodily organ or part.
Emergency transports (in- and out-of-network) are covered. They do not require an authorization.
Bill ambulance transport as a non-emergency transport when it doesn’t meet the definition of an emergency transport. This includes all scheduled runs and transports to nursing facilities or the member’s residence.
UnitedHealthcare Community Plan members may get non-emergent transportation services through Logisticare for covered services. Covered transportation includes sedan, taxi, wheelchair-equipped vehicle, public transit, mileage repayment and shared rides. Members may get transportation when:
- They are bed-confined before, during and after transport; and
- The services cannot be provided at their home (including a nursing facility or ICF/MR).
If the member resides in an area not served by the public bus or cannot take the public bus because of their medical condition or disability, they may be able to take public para-transit transportation. Every island has different public para-transit transportation arrangements. The member’s Service Coordinator can see if the member is eligible.
For public para-transit eligible members, we (through Logisticare) provide ride coupons. Members should call Logisticare five days in advance so the coupons may be mailed. Members with recurring trips are given coupons based on the number of medical or authorized non- medical trips as determined by the Service Coordinator or PCP.
Value-added non-emergent transportation services include substance abuse support groups, WIC appointments, parenting classes such as Lamaze, and pregnancy, health and wellness classes and meetings.
For non-urgent appointments, members must call for transportation no more than 48 hours in advance before their appointment. Requests can be made by phone at 866-475-5744 or fax 866-475-5745.
Ambulance services for a member receiving inpatient hospital services are not included in the payment to the hospital. They must be billed by the ambulance provider. This includes transporting the member to another facility for services (e.g., diagnostic testing) and returning them to the first hospital for more inpatient care.
For recurring appointments, such as dialysis or adult day care, the member’s Service Coordinator, PCP or the care provider must make the appointment request by calling Logisticare’s Facility Line at 866-475-5744 (or via the Facility fax number 866-475-5745). The request must be made once per quarter.
Discharges from a facility are considered an Urgent Transportation Request. Facilities may call Logisticare’s Facility Line at 866-475-5744 (or via the Facility fax number 866-475-5745) to arrange transport.
Members must call between 7:45 a.m. – 4:30 p.m. HST, Monday through Friday, to schedule transportation. If they have questions about their order, they may call Logisticare.
Bus transportation will also be available if the member:
- Lives less than half a mile from a bus stop.
- Has an appointment less than half a mile from the bus stop.
Taxis are not utilized unless no other transport is available and the need is urgent.
We must authorize all non-emergent off-island transports. Off-island transportation arrangements, to include air and land travel, are based on the specifics of the member’s appointment. The air transportation form is available on UHCprovider.com/hicommunityplan > For Healthcare Professionals > Hawaii > Manuals and Forms.
Urgent Air Transportation Requests:
Contact: UnitedHealthcare Community Plan 888-362-3368
Timeframe: At least three business days advance notice.
Phone: 888-980-8728, TTY: 711 (for hearing impaired)
Non-Emergency Air Transportation Requests (including transportation needed as part of air transportation)
Contact: UnitedHealthcare Community Plan 888-362-3368
Timeframe: At least 14 calendar days advance notice.
Phone: 888-980-8728, TTY: 711 (for hearing impaired)
Routine Ground Transportation (not part of the air transportation)
Contact: Logisticare (Transportation Vender)
Timeframe: Routine ground transportation requires a 48 hour advance request. Requests for a Monday trip should be made by Thursday at noon.
Special Instructions: If ground transportation is needed as part of an air transportation request, please check the box at the bottom of the Transportation Form. If the member also needs ground transportation from his/her home to and from the airport on the date of travel, please specify the member’s physical address to ensure timely pickup and drop off.
Meals and Lodging
We cover meals and lodging as part of an authorized medically necessary travel in-and-out of state.
For in-state travel, we give meal vouchers for the member and one escort.
For out-of-state travel, we reimburse meals for member and one approved escort. We require receipt or confirmation of expenses. Reimbursement for meals will not exceed $30.00 per person per day.
An escort is an individual who is needed to assist a member during transport or while at the place of
treatment. An escort is allowed for members under the age of 19. The member must prove a need for an escort. Transportation for more than one escort must be prior authorized by the PCP or Service Coordinator. The PCP must submit the medical certification form before we authorize the escort. The certification must document that the member has a physical, cognitive or mental disability requires assistance.
Transportation Not Covered
We will not reimburse or provide transportation for the following:
- Services in which prior authorization is required but was not obtained
- Services that are not medically necessary or which are not provided in compliance with the provisions of the UnitedHealthcare Community Plan QUEST Integration program
- Taxi service that is to/from ongoing or recurring services such as, but not limited to: Methadone Clinics, Community Mental Health Centers, physical, occupational and speech therapy appointments
- Supplemental Security Income (SSI) determination medical appointment
- Non-medical services
- Travel out of the country
- Return trip to the State of Hawai’i or inter-island unless the trip was pre-authorized in advance by the Plan; or
- Travel or associated expenses that are covered by another government agency, insurer, or private organization.
Durable Medical Equipment (DME) is equipment that provides therapeutic benefits to a member because of certain medical conditions and/or illnesses. DME consists of items which are:
- Primarily used to serve a medical purpose
- Not useful to a person in the absence of illness, disability, or injury
- Ordered or prescribed by a care provider
- Repeatedly used
- Appropriate for home use
- Determined to be medically necessary
See our Coverage Determination Guidelines at UHCprovider.com > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community Plan
Emergency services are any covered inpatient and outpatient services that are furnished by a care provider that is qualified to furnish services and that are needed to evaluate or stabilize an emergency medical condition.
Inpatient and outpatient emergency health services are covered inside or outside of our service area. In the event of an emergency, the member should seek immediate care, or call 911 for assistance. Prior authorization is not required, and we will not deny payment if a contracted care provider instructs a member to seek emergency services.
UnitedHealthcare Community Plan provides coverage for the treatment of an emergency medical condition, which is defined by DHS as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
- placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
- serious impairment to bodily functions;
- serious dysfunction of any bodily organ or part;
- serious harm to self or others due to an alcohol or drug abuse emergency;
- injury to self or bodily harm to others; or
- with respect to a pregnant woman having contractions: 1) that there is not adequate time to effect a safe transfer to another hospital before delivery, or 2) that transfer may pose a threat to the health or safety of the woman or her unborn child.
An emergency medical condition shall not be defined on the basis of lists of diagnoses or symptoms.
UnitedHealthcare Community Plan will base coverage decisions for emergency services on the severity of the symptoms at the time of presentation and will cover emergency services when the presenting symptoms are of sufficient severity to constitute an emergency condition in the judgment of a prudent layperson. The ER physician or the treating provider is responsible for determining when the member is sufficiently stabilized for transfer or discharge.
We do not limit what constitutes an emergency medical condition based on a list of diagnoses or symptoms. We do not refuse to cover emergency services based on the ER provider, hospital or fiscal agent not notifying the member’s PCP or UnitedHealthcare Community Plan of the member’s screening and treatment within ten calendar days of presentation for emergency services.
We do not hold the member, who has an emergency medical condition, liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient. We accept the emergency physician or provider’s determination of when the member is sufficiently stabilized for transfer or discharge.
UnitedHealthcare Community Plan includes coverage for post-stabilization services. Post-stabilization services are provided after a member is stabilized after a related emergency medical condition to maintain the stabilized condition or to improve or resolve the member’s condition. The attending physician or health care provider determines when the condition is no longer an emergency and the member is considered stabilized for discharge or transfer. Continuation of care after the condition is no longer an emergency will require coordination with UnitedHealthcare Community Plan.
Such automatic approval of post-stabilization services continues to be covered until UnitedHealthcare Community Plan has responded to the request and arranged for discharge or transfer.
UnitedHealthcare Community Plan includes coverage for urgently needed health services and symptomatic office visits. A symptomatic office visit is an encounter associated with a presentation of medical symptoms or signs, but not requiring immediate attention. Urgent care is the diagnosis and treatment of medical conditions which are serious or acute but pose no immediate threat to life and health but which require medical attention within 24 hours.
Urgent care is appropriately provided in a clinic, in a physician’s office, or in a hospital emergency department if a clinic or physician’s office is inaccessible. Urgent care does not include primary care services or services provided to treat emergency conditions. Urgently needed services are also covered when obtained from any provider within the UnitedHealthcare Community Plan service area in extraordinary cases in which UnitedHealthcare Community Plan contracted providers are unavailable or inaccessible due to an unusual event.
Our contracted care providers must notify us if a member is admitted to the hospital. The PCP should work with the attending physician to coordinate transfer to a contracted facility as soon as it is medically appropriate to do so.
Urgent Care (Non-Emergent)
Urgent care services are covered.
For a list of urgent care centers, contact Provider Services at 888-980-8728.
Prior authorization is not required for emergency services.
Emergency care should be delivered without delay. Notify UnitedHealth Community Plan about admission. Call the Prior Authorization Department or fax your Prior Authorization Form within 24 hours, unless otherwise noted. The form is available at UHCprovider.com/hicommunityplan > Prior Authorization and Notification.
Nurses in the Health Services Department review emergency admissions within one business day of notification.
UnitedHealthcare Community Plan makes utilization management determinations based on appropriateness of care and benefit coverage existence using evidence- based, nationally recognized or internally developed clinical criteria. UnitedHealthcare Community Plan
does not reward you or reviewers for issuing coverage denials and does not financially incentivize Utilization Management staff to support service underutilization. Care determination criteria is available upon request by contacting the Prior Authorization Department (UM Department, etc.).
The criteria are available in writing upon request or by calling the Prior Authorization Department.
If a member meets an acute inpatient level of stay, admission starts at the time you write the order.
Facilities are responsible for Admission Notification for the following inpatient admissions (even if an advanced notification was provided prior to the actual admission date):
- Planned/elective admissions for acute care
- Unplanned admissions for acute care
- Skilled Nursing Facility (SNF) admissions
- Admissions following outpatient surgery
- Admissions following observation
Family Planning services are preventive health, medical, counseling and educational services that help members manage their fertility and achieve the best reproductive and general health. UnitedHealthcare Community Plan members may access these services without a referral.
They may also seek family planning services at the care provider of their choice. The following services are included:
- Annual gynecological examination
- Annual pap smear
- Contraceptive supplies, devices and medications for specific treatment
- Diagnosis and treatment of sexually transmitted diseases
- Contraceptive counseling
- Emergency contraception
- Laboratory services
- Pregnancy testing
Blood tests to determine paternity are covered only when the claim indicates tests were necessary for legal support in court.
Non-covered items include:
- Reversal of voluntary sterilization
- Hysterectomies for sterilization
- In-vitro fertilization, including:
- GIFT (Gamete intrafallopian transfer)
- ZIFT (zygote intrafallopian transfer)
- Embryo transport
- Infertility services, if given to achieve pregnancy Note: Diagnosis of infertility is covered. Treatment is not.
Parenting / Child Birth Education Programs
- Child birth education is covered.
- Parenting education is not covered.
In-network treatment with consent is covered. The member needs to give consent 30 days before surgery, be mentally competent and be at least 21 years old at the time of consent for:
- Tubal ligation
Out-of-network services require prior authorization.
View the DHS Regulations for more information on sterilization.
Our health education program is led by our qualified, full- time health education manager. You are encouraged to collaborate with us to ensure health education services are provided to members. This program is a proactive approach to help members manage specific conditions and support them as they take responsibility for their health.
The program goals are to:
- Provide members with information to manage their condition and live a healthy lifestyle
- Improve the quality of care, quality of life and health outcomes of members
- Help individuals understand and actively participate in the management of their condition, adherence to treatment plans, including medications and self- monitoring
- Reduce unnecessary hospital admissions and ER visits
- Promote care coordination by collaborating with providers to improve member outcomes
- Prevent disease progression and illnesses related to poorly managed disease processes
- Support member empowerment and informed decision making
- Effectively manage their condition and co-morbidities, including depression, cognitive deficits, physical limitations, health behaviors and psychosocial issues
Our program makes available population-based, condition-specific health education materials, websites, interactive mobile apps and newsletters that include recommended routine appointment frequency, necessary testing, monitoring and self-care. We send health education materials, based upon evidence-based guidelines or standards of care, directly to members that address topics that help members manage their condition. Our program provides personalized support to members in case management. The case manager collaborates with the member to identify educational opportunities, provides the appropriate health education and monitors the member’s progress toward management of the condition targeted by the health education program.
Programs are based upon the findings from our Health Education, Cultural and Linguistic Group Needs Assessment (GNA) and will identify the health education, cultural and linguistic needs.
UnitedHealthcare Community Plan provides in-home hospice and short-stay inpatient hospice. These services require prior authorization.
Advanced Outpatient Imaging Procedures
Advanced outpatient imaging procedures must be prior authorized by UnitedHealthcare Community Plan Clinical.
Find a list of imaging procedures on UHCprovider.com/hicommunityplan > Prior Authorization and Notification. To get prior authorization, go to UHCprovider.com/ priorauth > click on the Radiology tab > Online Portal link, or call 888-980-8728.
Reference the Medical Management chapter for more information on the Radiology Prior Authorization Program.
Use UnitedHealthcare Community Plan in-network laboratory when referring members for lab services not covered in the office. Medically necessary laboratory services ordered by a PCP, other care providers or dentist in one of these laboratories do not require prior authorization except as noted on our prior authorization list.
For more information on our in-network labs, go to: https://www.uhcprovider.com/en/find-a-provider-referral-directory/preferred-lab-network.html
When submitting claims, have a Clinical Laboratory Improvement Amendment number (CLIA #). Otherwise, claims will deny. CLIA standards are national and not Medicaid-exclusive. CLIA applies to all providers rendering clinical laboratory and certain other diagnostic services.
See the Billing and Encounters chapter for more information.
Pregnancy / Maternity
Bill the initial pregnancy visit as a separate office visit. You may bill global days if the mother has been a UnitedHealthcare Community Plan member for three or more consecutive months or had seven or more prenatal visits.
For more information about global days, go to UHCprovider.com.
Pregnant UnitedHealthcare Community Plan members should receive care from UnitedHealthcare Community Plan care providers only. UnitedHealthcare Community Plan considers exceptions to this policy if:
- the woman was in her second or third trimester of pregnancy when she became a UnitedHealthcare Community Plan member, and
- if she has an established relationship with a non-participating obstetrician.
UnitedHealthcare Community Plan must approve all out-of-plan maternity care. Care providers should call 866-604-3267 to obtain prior approval for continuity of care.
Care providers should notify UnitedHealthcare Community Plan immediately of a member’s confirmed pregnancy to help ensure appropriate follow-up and coordination by the Hāpai Mālama program.
To notify UnitedHealthcare Community Plan of pregnancies, care providers should call Hāpai Mālama at 888-980-8728 (TTY users: 711) or fax the notification to 800-267-8328.
A UnitedHealthcare Community Plan member does not need a referral from her PCP for ob-gyn care. Perinatal home care services are available for UnitedHealthcare Community Plan members when medically necessary.
All maternity admissions require notification. Days in excess of 48 hours for vaginal deliveries and 96 hours for C-section require clinical information and medical necessity review.
If the UnitedHealthcare Community Plan member is inpatient longer than the federal requirements, a prior notification is needed. Please go to UHCprovider.com/priorauth or call the Prior Authorization Department.
To notify UnitedHealthcare Community Plan of deliveries, call 866-604-3267 or fax to 800-897-8317. Provide the following information within one business day of the admission:
- Date of admission.
- Member’s name and Medicaid ID number.
- Obstetrician’s name, phone number, care provider ID.
- Facility name (care provider ID).
- Vaginal or cesarean delivery.
If available at time of notification, provide the following birth data:
- Date of delivery.
- Birth weight.
- Gestational age.
- Baby name.
Non-routine newborn care (e.g., unusual jaundice, prematurity, sepsis, respiratory distress) is covered but requires prior authorization. Infants remaining in the hospital after the mother’s discharge require separate notification and will be subject to medical necessity review. The midwife (CNM) must be a licensed registered nurse recognized by the Board of Nurse Examiners as an advanced practice nurse (APN) in nurse-midwifery and certified by the American College of Nurse-Midwives.
A CNM must identify a licensed care provider or group of care providers with whom they have arranged for referral and consultation if complications arise.
Furnish obstetrical maternity services on an outpatient basis. This can be done under a physician’s supervision through a nurse practitioner, physician’s assistant or licensed professional nurse. If handled through supervision, the services must be within the staff’s scope of practice or licensure as defined by state law.
You do not have to be present when services are provided. However, you must assume professional responsibility for the medical services provided and help ensure approval of the care plan.
Post Maternity Care
UnitedHealthcare Community Plan covers post-discharge care to the mother and her newborn. Post-discharge care consists of a minimum of two visits according to accepted maternal and neonatal physical assessments. These visits must be conducted by a registered professional nurse with experience in maternal and child health nursing or a care provider. The first post-discharge visit should occur within 24 to 48 hours after the member’s discharge date. Prior authorization is required for home health care visits for post-partum follow-up. The attending care provider decides the location and post-discharge visit schedule.
The hospital is responsible to notify the county of all deliveries, including UnitedHealthcare Community Plan members.
If the mother delivers out of state, the member would need to contact the Enrollment Department to provide birth notification. The Enrollment Department would then add the baby to the health plan.
The hospital provides enrollment support by providing required birth data during admission.
Bright Futures Guideline
Bright Futures is a national health promotion and prevention initiative, led by the American Academy of Pediatrics and supported by the US Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB).
The Bright Futures Guideline provides guidance for all preventive care screenings and well-child visits. The state of Hawaii Med-QUEST division recommends using Bright Futures into your daily practice. The AAP/ Bright Futures periodicity schedule and guideline are at brightfutures.aap.org.
The primary goal of Bright Futures is to support primary care practices (medical homes) in providing well-child and adolescent care according to Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Settings for Bright Futures include private practices, hospital-based or hospital-affiliated clinics, resident continuity clinics, school-based health centers, public health clinics, and community health centers.
The state of Hawaii Med-QUEST division supports the Bright Futures’ Medical home model and recommends using the State’s Rainbow Book Resource Guide. It is a medical home resource directory for children and youth with special health care needs.
Home Care and All Prior Authorization Services
The discharge planner ordering home care should call the Prior Authorization Department to arrange for home care.
Hysterectomies cannot be reimbursed if performed for sterilization. Members who get hysterectomies for medical reasons must be told, orally and in writing, they will no longer be able to have children.
All hysterectomy claims (surgeon, assistant surgeon, anesthesiologist, hospital) must be accompanied by a consent form. The member should sign and date the form stating she was told before the surgery that the procedure will result in permanent sterility.
Find the form medquest.hawaii.gov.
Exception: Hawaii DHS does not require informed consent if:
- As the care provider performing the hysterectomy, you certify in writing the member was sterile before the procedure. You must also state the cause of sterility.
- You certify, in writing, the hysterectomy was performed under a life-threatening emergency situation in which prior acknowledgment was not possible. Include a description of the emergency.
UnitedHealthcare Community Plan requires, along with your claim, a copy of the signed medical assistance hysterectomy statement. Mail the claim and documentation to claims administration identified on the back of the member’s ID card. Reimbursement is made upon completion of documentation requirements and UnitedHealthcare Community Plan review. The member may not be billed if consent forms are not submitted.
Pregnancy Termination Services
Pregnancy termination services are not covered, except in cases to preserve the woman’s life. In this case, follow the Hawaii consent procedures for abortion.
Allowable pregnancy termination services do not require a referral from the member’s PCP. Members must use the UnitedHealthcare Community Plan care provider network.
Sterilization and Hysterectomy Procedures
Reimbursement for sterilization procedures are based on the member’s documented request. This policy helps ensure UnitedHealthcare Community Plan members thinking about sterilization are fully aware of the details and alternatives. It also gives them time to consider their decision. In addition, the State Medical Assistance Program must have documented evidence that all the sterilization requirements have been met before making a payment. The member must sign the Medical Assistance Consent Form at least 30 days, but not more than 180 days, before the procedure. The member must be at least 21 years old when they sign the form.
The member must not be mentally incompetent or live in a facility treating mental disorders. The member may agree to sterilization at the time of premature delivery or emergency abdominal surgery if at least 72 hours have passed since signing the consent form. However, in the case of premature delivery, they must have signed the form at least 30 days before the expected delivery date. If the requirements are not met for both sterilization procedures and hysterectomies, UnitedHealthcare Community Plan cannot pay the care provider, anesthetist or hospital.
Sterilization Informed Consent
A member has only given informed consent if the Hawaii Department of Social Services Medical Assistance Consent Form for sterilization is properly filled out. Other consent forms do not replace the Medical Assistance Consent Form. Be sure the member fully understands the sterilization procedure and has been told of other family planning options. Informed consent may not be obtained while the member is in labor, seeking an abortion, or under the influence of alcohol or other substances that affect awareness.
Sterilization Consent Form
Use the consent form for sterilization:
- Complete all applicable sections of the form. Complete all applicable sections of the consent form before submitting it with the billing form. The Hawaii Medical Assistance Program cannot pay for sterilization procedures until all applicable items on the consent form are completed, accurate and follow sterilization regulation requirements.
- Your statement section should be completed after the procedure, along with your signature and the date. This may be the same date of the sterilization or a date afterward. If you sign and date the consent form before performing the sterilization, the form is invalid.
- The state’s definition of “shortly before” is not more than 30 days before the procedure. Explain the procedure to the member within that time frame. However, do not sign and date the form until after you perform the procedure.
You may also find the form on medquest.hawaii.gov.
Have three copies of the consent form:
- For the member.
- To submit with the Request for Payment form.
- For your records.
Our Neonatal Resource Services (NRS) program manages inpatient and post-discharge neonatal intensive care unit (NICU) cases to improve outcomes and lower costs. Our dedicated team of NICU nurse case managers, social workers and medical directors offer both clinical care and psychological services.
Neonatal Resource Services
The NRS program helps ensure NICU babies get quality of care and efficiency in treatment. Newborns placed in the NICU are eligible upon birth (including babies who are transferred from PICU) and/or any infants readmitted within their first 30 days of life and previously managed in the NICU. The NRS follows all babies brought to the NICU.
NRS neonatologists and NICU nurses manage NICU members through evidence-based medicine and care plan use.
The NRS nurse case manager will:
- Work with the family, the care providers, and the facility discharge planner to help ensure timely discharge and service delivery.
- Develop care management strategies and interventions based on infant and family needs.
- Coordinate services prior to discharge and after discharge if the member is under NRS case management.
The NRS nurse case manager’s role includes:
- Planning and arranging the discharge.
- Coordinating care options and prior authorization, including home care, equipment and skilled nursing.
- Arranging post-discharge support for a minimum of 30 days and up to 15 months based on infant ongoing acuity
- Educating parents and families about available local resources and support services.
- Coordination with the Whole Person Care Team for additional case management needs and services.
Case managers provide benefit solutions to help families get the right services for the baby.
Inhaled Nitric Oxide
Use the NRS guideline for Inhaled Nitric Oxide (iNO) therapy at UHCprovider.com > Polices and Protocols > Clinical Guidelines
This is a service offered to enable individuals to gain access to community services, activities, and resources, specified by the service plan. Whenever possible, family, neighbors, friends, or community agencies that can provide this service without charge will be utilized. Members living in a residential care setting or a CCFFH are not eligible for this service.
Visit UHCprovider.com/hicommunityplan > Pharmacy Resources and Physician Administered Drugs for pharmacy prior authorization forms, Preferred Drug Lists (PDLs), and other important pharmacy information.
Pharmacy Prior Authorization
Medications can be dispensed as an emergency 72-hour supply when drug therapy must start before prior authorization is secured and the prescriber cannot be reached. The rules apply to non-preferred PDL drugs and to those affected by a clinical prior authorization edit.
To request pharmacy prior authorization, call the OptumRx Pharmacy Help Desk at 800-310-6826. You may also fax your authorization request to 866-940-7328. We provide notification for prior authorization requests within 24 hours of request receipt.
Pharmacy Preferred Drug List
UnitedHealthcare Community Plan determines and maintains its PDL of covered medications. This list applies to all UnitedHealthcare Community Plan of Hawaii members.
You must prescribe Medicaid members drugs listed on the PDL. We may not cover brand-name drugs not on the PDL if an equally effective generic drug is available and is less costly unless prior authorization is followed.
If a member requires a non-preferred medication, call the Pharmacy Prior Authorization department at 800-310- 6826. You may also fax a Pharmacy Prior Notification Request form to 866-940-7328.
We provide you PDL updates before the changes go into effect. Change summaries are posted on UHCprovider.com. Find the PDL and Pharmacy Prior Notification Request form at UHCprovider.com/priorauth.
Home Delivery (Medicare-Medicaid Eligible)
We offer mail order – home delivery – pharmacy services to Medicare and Medicaid Eligible (MME) members.
To assist members in arranging mail order pharmacy services, please have the member contact OptumRx at 877-889-6358.
We use a Radiology Prior Authorization Program to improve compliance with evidence-based and professional society guidance for radiology procedures.
You must obtain a prior authorization before ordering CT scans, MRIs, MRAs, PET scans, nuclear medicine and nuclear cardiology studies in an office or outpatient setting.
The following images do not require prior authorization:
- Ordered through ER visit.
- While in an observation unit.
- When performed at an urgent care facility.
- During an inpatient stay.
Not getting this prior authorization approval results in an administrative denial. Claims denied for this reason may not be balance-billed.
To get or verify prior authorization:
- Online: UHCprovider.com/priorauth > Radiology > Online Portal link.
- Phone: 866-889-8054 from 8 a.m. – 5 p.m. Central Time, Monday through Friday. Make sure the medical record is available. An authorization number is required for each CPT code. Each authorization number is CPT-code specific.
For a list of Advanced Outpatient Imaging Procedures that require prior authorization, a prior authorization crosswalk, and/or the evidence-based clinical guidelines, refer to UHCprovider.com/hicommunityplan > Prior Authorization and Notification.
SBIRT services are covered when:
- Provided by, or under the supervision of, a certified care provider or other certified licensed healthcare professional within the scope of their practice.
- Determining risk factors related to alcohol and other drug use disorders, providing interventions to enhance patient motivation to change, and making appropriate referrals as needed.
- SBIRT screening will occur during an Evaluation and Management (E/M) exam and is not billable with a separate code. You may provide a brief intervention on the same day as a full screen in addition to the E/M exam. You may also perform a brief intervention on subsequent days. Brief interventions are limited to four sessions per patient, per provider per calendar year.
What Is Included In SBIRT?
Screening: With just a few questions on a questionnaire or in an interview, you can identify members who have alcohol or other drug (substance) use problems and determine how severe those problems already are. Three of the most widely used screening tools are the Alcohol Use Disorders Identification Test (AUDIT), the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and the Drug Abuse Screening Test (DAST).
Brief intervention: If screening results indicate at risk behavior, individuals receive brief interventions. The intervention educates them about their substance use, alerts them to possible consequences and motivates them to change their behavior.
Referral to treatment: Refer members whose screening indicates a severe problem or dependence s to a licensed and certified behavioral health agency for assessment and treatment of a substance use disorder. This includes coordinating with the Alcohol and Drug Program in the County where the member resides for treatment.
SBIRT services will be covered when all of the following are met:
- The billing provider and servicing provider are SBIRT certified.
- The billing provider has an appropriate taxonomy to bill for SBIRT.
- The diagnosis code is V65.42.
- The treatment or brief intervention does not exceed the limit of four encounters per client, per provider, per year.
The SBIRT assessment, intervention, or treatment takes places in one of the following places of service:
- Urgent care facility
- Outpatient hospital
- ER – hospital
- Federally qualified health center (FQHC)
- Community mental health center
- Indian health service – freestanding facility
- Tribal 638 freestanding facility
- Homeless shelter
For more information about E/M services and outreach, see the Department of Health and Human Services Evaluation and Services online guide at cms.gov.
Medication-assisted treatment (MAT) combines behavioral therapy and medications to treat Opioid Use Disorders (OUD). The Food and Drug Administration (FDA) approved medications for OUD include Buprenorphine, Methadone, and Naltrexone.
To prescribe Buprenorphine, you must complete the waiver through the Substance Abuse and Mental Health Services Administration (SAMHSA) and obtain a unique identification number from the United States Drug Enforcement Administration (DEA).
As s medical care provider, you may provide MAT services even if you don’t offer counseling or behavioral health therapy in-house. However, you must refer your patients to a qualified care provider for those services. If you need help finding a behavioral health provider, call the number on the back of the member’s health plan ID card or search for a behavioral health professional on liveandworkwell.com.
To find a medical MAT provider in Hawaii:
- Go to UHCprovider.com
- Select “Find a Provider” from the menu on the home page
- Select “Search for Care Providers in the General UnitedHealthcare Plan Directory”
- Click on “Medical Directory”
- Click on “Medicaid Plans”
- Click on applicable state
- Select applicable plan
- Refine the search by selecting “Medication Assisted Treatment”
For more SAMHSA waiver information: Physicians — samhsa.gov
Nurse Practitioners (NPS) and Physician Assistants (PAs) — samhsa.gov
If you have questions about MAT, please call Provider Services at 877-842-3210, enter your Tax Identification Number (TIN) then say: "Representative," and "Representative" a second time, then "Something Else" to speak to a representative.
The Specialty Pharmacy Management Program provides high-quality, cost-effective care for our members. A specialty pharmacy medication is a high-cost drug that generally has one or more of the following characteristics:
- Used by a small number of people
- Treats rare, chronic, and/or potentially life-threatening diseases
- Has special storage or handling requirements such as needing to be refrigerated
- May need close monitoring, ongoing clinical support and management, and complete patient education and engagement
- May not be available at retail pharmacies
- May be oral, injectable, or inhaled
Specialty pharmacy medications are available through our specialty pharmacy network.
Guidelines for TB screening and treatment should follow the recommendations of the American Thoracic Society (ATS) and the Centers for Disease Control and Prevention (CDC).
Identification – The PCP determines the risk for developing TB as part of the initial health assessment. Testing is offered to all members at increased risk unless they have documentation of prior positive test results or currently have active TB under treatment. You will coordinate and collaborate with Local Health Departments (LHDs) for TB screening, diagnosis, treatment, compliance, and follow-up of members. PCPs must comply with all applicable state laws and regulations relating to the reporting of confirmed and suspected TB cases to the LHD. The PCP must report known or suspected cases of TB to the LHD TB Control Program within one day of identification.
Human Immunodeficiency Virus (HIV) / Acquired Immune Deficiency Syndrome (AIDS) HCBS Waiver Program
The HIV/AIDS in-home waiver services program is available to members who would otherwise require long- term institutional services.
Identification – Members with symptomatic HIV or AIDS who require nursing home level of care services may be eligible for the waiver. The care coordinator or the PCP may identify members potentially eligible for the waiver program. They may also inform the member of the waiver program services.
Referral – If the member agrees to participation, provide the waiver agency with supportive documentation including history and physical, any relevant labs or other diagnostic study results and current treatment plan.
Continuity of Care – The HIV/AIDS waiver program will coordinate in-home HCBS services in collaboration with the PCP and care coordinator. If the member does not meet criteria for the waiver program, or declines participation, the health plan will continue care coordination as needed to support the member.
Other Federal Waiver Programs
Other waiver services, including the Nursing Facility Acute Hospital Waiver, may be appropriate for members who may benefit from HCBS services. These members are referred to the Long Term Care Division / HCBS Branch to determine eligibility and availability. If deemed eligible, the health plan will continue to cover all medically necessary covered services for the member unless/until member is disenrolled from the Medicaid Program.
Admission Authorization and Prior Authorization Guidelines
All prior authorizations must have the following:
- Patient name and ID number.
- Ordering care provider or health care professional name and TIN/NPI.
- Rendering care provider or health care professional and TIN/NPI.
- ICD CM.
- Anticipated dates of service.
- Type of service (primary and secondary) procedure codes and volume of service, when applicable.
- Service setting.
- Facility name and TIN/NPI, when applicable.
For behavioral health and substance use disorder authorizations, please contact Optum Behavioral Health.
Locate the Prior Authorization Fax Request Form at UHCprovider.com/hicommunityplan > Prior Authorization and Notification. If you have questions, please call Prior Authorization Intake.
These services are not covered by UnitedHealthcare Community Plan but are offered through the state or other local agency. See Chapter 6: Benefits: Covered, Excluded and Value-Added for more information on these services.
- Behavioral Health Services
- Developmental Disabled/Intellectually Disability (DD/ID) Services
- Dental Services
- School Based Services
- Zero to Three Services
- State of Hawai’i Organ and Transplant (SHOTT) Program
We provide case management services to members with complex medical conditions or serious psychosocial issues. The Medical Case Management Department assesses members who may be at risk for multiple hospital admissions, increased medication use, or would benefit from a multidisciplinary approach to medical or psychosocial needs.
Refer members for case management by calling Care Management at 888-980-8728. Additionally, UnitedHealthcare Community Plan provides the Hāpai Mālama program, which manages women with high-risk pregnancies.
UnitedHealthcare Community Plan requires you to chart progress notes for each day of an inpatient stay. This includes acute and sub-acute medical, long-term acute care, acute rehabilitation, skilled nursing facilities, home health care and ambulatory facilities. We perform an on-site facility review or phone review for each day’s stay using MCG, CMS or other nationally recognized guidelines to help clinicians make informed decisions in many health care settings. You must work with UnitedHealthcare Community Plan for all information, documents or discussion requests. This includes gathering clinical information on a member’s status for concurrent review and discharge planning. When criteria are not met, the case is sent to a medical director.
UnitedHealthcare Community Plan denies payment for days that do not have a documented need for acute care services. Failure to document results in payment denial to the facility and you.
Concurrent Review Details
Concurrent Review is notification within 24 hours or one business day of admission. It finds medical necessity clinical information for a continued inpatient stay, including review for extending a previously approved admission. Concurrent review may be done by phone or on-site.
Your cooperation is required with all UnitedHealthcare Community Plan requests for information, documents or discussions related to concurrent review and discharge planning including: primary and secondary diagnosis, clinical information, care plan, admission order, member status, discharge planning needs, barriers to discharge and discharge date. When available, provide clinical information by access to Electronic Medical Records (EMR).
Your cooperation is required with all UnitedHealthcare Community Plan requests from our interdisciplinary care coordination team and/or medical director to support requirements to engage our members directly face-to- face or by phone. You must return/respond to inquiries from our interdisciplinary care coordination team and/ or medical director. You must provide all requested and complete clinical information and/or documents as required within four hours of receipt of our request if it is received before 1 p.m. local time, or make best efforts to provide requested information within the same business day if the request is received after 1 p.m. local time (but no later than 12 p.m. local time the next business day).
UnitedHealthcare Community Plan uses MCG (formally Milliman Care Guidelines), CMS guidelines, or other nationally recognized guidelines to assist clinicians in making informed decisions in many health care settings. This includes acute and sub-acute medical, long-term acute care, acute rehabilitation, skilled nursing facilities, home health care and ambulatory facilities.
Medically necessary services or supplies are those necessary to:
- Prevent, diagnose, alleviate or cure a physical or mental illness or condition.
- Maintain health.
- Prevent the onset of an illness, condition or disability.
- Prevent or treat a condition that endangers life, causes suffering or pain or results in illness or infirmity.
- Prevent the deterioration of a condition.
- Promote daily activities; remember the member’s functional capacity and capabilities appropriate for individuals of the same age.
- Prevent or treat a condition that threatens to cause or worsen a handicap, physical deformity, or malfunction; there is no other equally effective, more conservative or substantially less costly treatment available to the member.
- Not experimental treatments
Support the opportunity for an enrollee receiving LTSS to have access to benefits of community living, to achieve person-centered goods, and to live and work in the setting of their choice.
Benefit coverage for health services is determined by the member specific benefit plan document, such as a Certificate of Coverage, Schedule of Benefits, or Summary Plan Description, and applicable laws. You may freely communicate with members about their treatment, regardless of benefit coverage limitations.
Hāpai Mālama is a specialized case management program designed to improve the health and well-being of all pregnant members. It gives particular attention to those with a High Risk Pregnancy and special health care needs. It tracks the member’s adherence to the recommended prenatal treatment plan. It also highlights activities and treatments that prevent prenatal and postpartum medical and behavioral health-related complications.
Hāpai Mālama Care Model
The Hāpai Mālama care model strives to:
- Identify pregnant members and to provide education on the importance of initiating prenatal care within the first trimester of pregnancy (or within 42 days of member health plan enrollment)
- Raise the number of pregnant members who are enrolled in the program
- Base member stratification on medical, behavioral health, long-term care and special healthcare needs
- Work with obstetrical care providers on condition monitoring, managing co-morbidities, and adherence to treatment plans
- Increase member awareness of pregnancy management, preventive health behaviors, importance of recognizing and reporting symptoms of early labor and/or pregnancy complications, and compliance with the service plan
- Raise adherence to prescribed medications
- Reduce environmental barriers to care related to transportation, translation services, and phone access in order to assure compliance with required appointments, laboratory and prenatal testing procedures
- Identify more members who use tobacco and refer them for smoking cessation
- Raise the percentage of pregnant members who get their post-partum exam 21-56 days post-partum
- Lower the rate of preterm deliveries annually
- Reduce the rate of low birth weight and very low birth weight infants
- Cut back the annual NICU admission rate and NICU length of stay
- Teach the importance of routine health exams and EPSDT check-ups
- Apply an integrated approach that uses Service Coordinators, Community Health Workers, Behavioral Health Advocates, Clinical Program Managers, Inpatient Care Managers, UM Managers, Quality Clinical Practice Managers, Medical Directors, and Nonclinical Support Staff, in a collaborative effort to increase timeliness of prenatal and postpartum care
Call us when a member becomes pregnant: 888-980-8728.
Find medical policies and coverage determination guidelines at UHCprovider.com > Policies and Protocols > Community Plan Policies > Medical and Drug Policies and Coverage Determination Guidelines for Community Plan.
You must coordinate member referrals for medically necessary services beyond the scope of your practice. Monitor the referred member’s progress and help ensure they are returned to your care as soon as appropriate.
We require prior authorization of all out of-network referrals. The nurse reviews the request for medical necessity and/or service. If the case does not meet criteria, the nurse routes the case to the medical director for review and determination. Out-of-network referrals are approved for, but not limited to, the following:
- Continuity of care issues
- Necessary services are not available within network
UnitedHealthcare Community Plan monitors out-of- network referrals on an individual basis. Care provider or geographical location trends are reported to Network Management to assess root causes for action planning.
UnitedHealthcare Community Plan authorization helps ensure reimbursement for all covered services. You should:
- Determine if the member is eligible on the date of service by using UHCprovider.com, contacting UnitedHealthcare Community Plan’s Provider Services Department, or the Hawaii Medicaid Eligibility System.
- Submit documentation needed to support the medical necessity of the requested procedure.
- Be aware the services provided may be outside the scope of what UnitedHealthcare Community Plan has authorized.
- Determine if the member has other insurance that should be billed first.
UnitedHealthcare Community Plan will not reimburse:
- Services UnitedHealthcare Community Plan decides are not medically necessary.
- Non-covered services.
- Services provided to members not enrolled on the date(s) of service.
If a UnitedHealthcare Community Plan member asks for a second opinion about a treatment or procedure, UnitedHealthcare Community Plan will cover that cost. Scheduling the appointment for the second opinion should follow the access standards established by the Hawaii DHS. These access standards are defined in Chapter 2. The care provider giving the second opinion must not be affiliated with the attending care provider.
- The member’s PCP refers the member to an in- network care provider for a second opinion. Providers will forward a copy of all relevant records to the second opinion care provider before the appointment. The care provider giving the second opinion will then forward his or her report to the member’s PCP and treating care provider, if different. The member may help the PCP select the care provider.
- If an in-network provider is not available, UnitedHealthcare Community Plan will arrange for a consultation with a non-participating provider. The participating provider should contact UnitedHealthcare Community Plan at Hawaii: 888-980-8728.
- Once the second opinion has been given, the member and the PCP discuss information from both evaluations.
- If follow-up care is recommended, the member meets with the PCP before receiving treatment.
Members receiving long-term services and supports (LTSS) and those with special health care needs (SHCN) are assigned a service coordinator.
Once the eligible member is identified, the Service Coordinator contacts member. If the member wishes to participate, they complete a comprehensive assessment of the member’s health status. With member input and participation, the Service Coordinator develops the member’s Service Plan. This includes:
- Making long-term and short-term goals
- Finding barriers to meeting goals or following the plan
- Documenting in the automated care management system
- Implementing automated tasks and reminders to ensure follow-up
The Service Coordinator utilizes evidence-based clinical practice guidelines for ongoing management and evaluation.
Service Coordinators sends copies of the LTSS/SHCN member service plans and reassessments to the PCP. They make calls to the PCP if they have specific concerns.
For PCPs with a higher volume of our LTSS/SHCN members, we have a more targeted approach. This include case reviews with the medical director with the PCP and other members of the care team and faxed service plans to PCP for their input and review.
Role of PCP in Service Coordination
The PCP serves as the point of initial contact and as the “medical home” for the member. They are responsible for:
- Providing medical oversight to the service coordination process
- Being fully aware of all services delivered
- Conducting face-to-face medical assessments
- Providing primary care medical services and coordinating care with in-network specialist physicians (out-of-network physicians via the prior authorization process), as needed
- Participating in the creation and maintenance of the service plan including establishing goals with the needs of the member
- Providing clinical education to the care team
- Working with the care team to provide the member and their family education in disease self- management
- Implementing care that is consistent with best practice guidelines and customizing for the member
- Collaborating with the Service Coordinator
- Supporting and facilitating connections with local community care and service providers
Role of Other Care Providers
Specialists, behavioral health providers, therapists, home and community based providers, assisted living services providers, and other care providers are included in the service planning process. They provide input into the development of the member’s service plan.
Service Coordinators work with these care providers to coordinate services and provide results of member assessments.
When to Contact Service Coordinators
You must contact a member’s Service Coordinator when:
- You cannot contact the member
- You cannot provide or arrange for medically necessary services
- There is a significant change in the member’s condition
- The member unexpectedly leaves their place of residence
- The member is admitted to the hospital
- The member suffers a fall
- There are skin integrity issues
- There are behavioral health issues
- The member elects hospice
- There is a bed hold and therapeutic leave request (Nursing Facilities only)
- The member needs outpatient therapies including PT/OT/ST/RT
- The member dies
You may contact your member’s service coordinator by calling Member Services at 888-980-8728. If you feel the member could benefit from Service Coordination but does not have currently have this benefit, you may refer that member to the Service Coordination Team for an assessment. You may call the Member Services Call Center at 888-980-8728 or use the Service Coordination Referral Form found at UHCprovider.com.
For a complete list of exclusions, contact Provider Services at 888-980-8728.
Certain services and service categories are excluded from coverage under the UnitedHealthcare Community Plan QUEST Integration Program. Certain Medicaid covered services may also be carved out and are provided by the state and/or other local agencies. The Member Handbook for the UnitedHealthcare Community Plan QUEST Integration Program also lists the excluded services for our members.
In addition to specific excluded or non-covered services, here is a list of some services excluded from the QUEST Integration program:
- Services typically excluded but, in extenuating circumstances and upon request, we will review for medical necessity:
- Services that are not medically necessary (as defined in Hawai’i statute);
- Services that are experimental or investigative;
- Non-emergent or non-urgent services provided out of state that have not been authorized in advance (post- stabilization services following emergent admission are covered);
- Non-emergent or non-urgent services provided by out-of-network care providers that have not been authorized in advance (post-stabilization services following emergent admission are covered; services provided by non-participating providers at an in- network facility are covered);
- Surgery for the member’s appearance, excluding authorized reconstructive surgery;
- Routine, restorative and cosmetic dental services (see Section on Services Available from other Agencies.), excluding certain authorized medical procedures related to dental work;
- Reversal of sterilization;
- Artificial insemination, in-vitro fertilization or any other treatment to create a pregnancy;
- Treatment of impotence;
- Hysterectomies that are performed solely or primarily for rendering a member permanently incapable of reproducing;
- Hysterectomies that are performed for the purpose of cancer prophylaxis;
- Physical exams or other services for work, school, sports or athletic events;
- Services that a member received before or after member’s eligibility with UnitedHealthcare Community Plan QUEST Integration program (inpatient hospital facility coverage will continue until the member is discharged or there is a change in level of care);
- Personal hygiene, luxury, or convenience items;
- Foot care for comfort or appearance, like flat feet, corns, calluses, toenails;
- Drugs for:
- hair growth
- controlling your appetite
- treatment of impotence
- treatment of infertility
- erectile dysfunction or similar “lifestyle” products
- Drugs that the Food and Drug Administration (FDA) says are:
- DESI – this means that research says they are not effective
- LTE – this means that research says they are less than effective
- IRS – this means that the drugs are identical, related, or similar to LTE drugs;
- Environmental modifications or home adaptations that solely add to the square footage of the home, are of general utility, or are in excess of standard modification costs;
- Laboratory and diagnostic tests that are experimental, investigational or generally unproven; chromosomal evaluations; IgG4 testing; and procedures related to storing, preparation and transfer of oocytes for in vitro fertilization; and
- Certain vision services such as orthoptic training, prescription fees, progress exams, radial keratotomy, visual training, and Lasik procedure.
- Services that are covered by another payer, such as Medicare;
- Any services outside of the United States;
- Autopsy or necropsy;
- Any services if the member is in local, state, or federal jail or prison;
- Any services otherwise provided to member by a local, state or federal agency or facility;
- Services that are covered by workers compensation insurance;
- UnitedHealthcare Community Plan QUEST Integration Medicaid hospice services provided to members receiving Medicare hospice services that is duplicative of Medicare hospice benefits. Examples include personal care and homemaker services. This is only covered when the service need is not related to the hospice diagnosis; and
- UnitedHealthcare Community Plan QUEST Integration Medicaid home health services when they are already covered by Medicare home health benefits (this exclusion applies only to members who also have Medicare).
For a list of services that require prior authorization and related forms, go to UHCprovider.com/hicommunityplan > Prior Authorization and Notification.
To receive prior authorization for prescriptions, you must contact UnitedHealthcare Pharmacy Prior Notification Services at 800-310-6826 or fax the prior authorization form to 866-940-7328.
Direct Access Services – Native Americans
Native Americans seeking tribal clinic or Indian Health hospital services do not require prior authorization.
Seek Prior Authorization within the Following Time Frames
- Emergency or Urgent Facility Admission: one business day.
- Inpatient Admissions; After Ambulatory Surgery: one business day.
- Non-Emergency Admissions and/or Outpatient Services (except maternity): at least 14 business days beforehand; if the admission is scheduled fewer than five business days in advance, use the scheduled admission time.
Call 888-980-8728 to discuss the guidelines and utilization management.
Utilization Management (UM) is based on a member’s medical condition and is not influenced by monetary incentives. UnitedHealthcare Community Plan pays its in-network PCPs and specialists on a fee-for-service basis. We also pay in-network hospitals and other types of care providers in the UnitedHealthcare Community Plan network on a fee-for-service basis. The plan’s UM staff works with care providers to help ensure members receive the most appropriate care in the place best suited for the needed services. Our staff encourages appropriate use and discourages underuse. The UM staff does not receive incentives for UM decisions.
You can discuss the requested services with the physician who will make the decision by calling our Medical Director at 888-980-8728, select option 1, and then option 1 again (for Medicaid) or 800-410-1925, select option 1 (for Medicare).
Utilization Management (UM) Appeals
These appeals contest UnitedHealthcare Community Plan’s UM decisions. They are appeals of UnitedHealthcare Community Plan’s admission, extension of stay, level of care, or other health care services determination. The appeal states it is not medically necessary or is considered experimental or investigational. It may also contest any admission, extension of stay, or other health care service due to late notification, or lack of complete or accurate information. Any member, their designee, or care provider who is dissatisfied with a UnitedHealthcare Community Plan UM decisions may file a UM appeal. See Appeals in Chapter 12 for more details.