FAQs & Quick Tips for Providers
Have a question about Express Scripts? Check out our page here.
A. Complete a Participating Provider Add Form and submit copies of the new physician's Hawaii State and Federal DEA licenses (if applicable). Please include the master vendor's TIN (Tax ID Number) and NPI (National Provider Identifier) number(s).
A. Yes. See the section on Electronic Funds Transfer (EFT).
A. Complete the Existing Provider Change form to report changes in billing address.
A. The provider/physician fee schedule is updated every two years, based on the prior year's Medicare rates.
A. Yes. Send a request in writing and we will send you a new unique PIN number. Submit your request to:
UHA Contracting Services
700 Bishop Street, Suite 300
Honolulu, HI 96813-4100
Toll free fax: (866) 572-4383
Email: [email protected]
A. The patient co-pay for a physician office visit is listed on the member ID card. Currently the co-payments are:
|UHA 600||10% of the eligible charge**|
*Insurance card should indicate if the co-payment is $12
**Tax on the physician office visit charge is not a covered benefit. The provider is responsible for calculating the tax portion based on the eligible charge. Co-payment amounts are subject to change without notice.
A. Online Claim status is now offered via Online Provider Services. For more information contact Customer Services at (808) 532-4000, or toll free at 1-800-458-4600 from the Neighbor Islands.
A. Yes. There are two ways to submit EDI claim submissions. A connection can be made directly to UHA as an 837 transaction or through the Hawaii Xchange online service. Click here to read more about each submission method.
A. Submit the Medicare Explanation of Benefit along with the claim form to UHA.
FAQs - Claim Reconsideration and Appeal
A. Refer to the diagram below. Please contact Customer Services if you need further assistance.
A. Yes, claims can be reconsidered for a variety of reasons. Please contact Customer Services for assistance.
A. If you are not satisfied with our response to your concern, you may file a formal appeal. The appeal must be filed within one year of the date UHA informed you of the denial or limitation of the claim or coverage for any requested service. You may appoint someone to represent you during the appeal process, such as a guardian or legal representative. Appeals and representative appointments must be submitted in writing to:
UHA Appeals Coordinator
700 Bishop Street, Suite 300
Honolulu, HI 96813
Your appeal will be reviewed by staff not involved in the original decision (nor a subordinate to the original decision maker). If the appeal concerns a clinical matter, it will be reviewed by an independent licensed practitioner with appropriate expertise and experience. If we need additional information to complete our review, we will notify you and give you reasonable time to respond.
For more information, please view our Provider Handbook.
The final decision will be made by the UHA Appeals Committee. You will be notified of the final decision within 60 days of receipt of your written appeal, or within 30 days if your appeal concerns a denial of a clinical matter.
Expedited AppealsA member, a member's legal representative, or the member's treating provider can request an expedited appeal (72-hour response time for UHA’s final internal determination):
- For an acute or urgent condition; or
- If the standard time (30 or 60 days, as set forth above) for completing an appeal would
- seriously jeopardize the member's life or health
- seriously jeopardize the member's ability to gain maximum functioning; or
- in the opinion of a physician with knowledge of the appellant's medical condition, subject the member to severe pain that cannot be adequately managed without the care or treatment requested.
- To request an expedited appeal, a member, member's representative, or member's treating provider, should contact Health Care Services. All necessary information regarding such urgent appeal may be submitted by telephone, fax, or other expeditious means.
A. If you wish to contest our decision on any appeal, you must agree to binding arbitration. To request binding arbitration, you must submit a written request for arbitration to UHA within 60 days of the date of the letter communicating the decision of the Appeals Committee. Both parties will agree on the person to serve as the independent arbitrator. The decision of the arbitrator is binding on both parties. Costs for the arbitration will be shared as ordered by the arbitrator. Further details are provided in your Participating
FAQs - Referrals and Authorizations
A. Primary care physicians (PCP) and other participating specialists may direct members to any participating specialist. A formal referral is not necessary.
A. Yes. In order to meet the needs of our members, our plans allow for this kind of flexibility.
A. The specialist that will be performing the procedure is responsible for obtaining authorization by completing a Request for Authorization form. The primary care physician (PCP) should also be notified.
A. Providers who have registered for Online Provider Services* may view the status of authorization requests online. Otherwise, approved requests are confirmed in writing and delivered either by mail or fax. You must receive more than verbal notification for non-emergency care.
* For more information about Online Provider Services, please click here.
A. We ask that you submit your prior authorization well in advance of the
service date(s), allowing two weeks (15 days) for a determination to be made.
A. You may, but be aware that expedited requests are defined as those which may seriously jeopardize life or health, or the ability to regain maximum functioning.
A. Not typically, but requests will be handled on a case-by-case basis. Complete a Request for Authorization form and submit it for consideration.
Quick Tips - Preventing Returned / Denied Claims
Reduce the time it takes to process your claim and avoid a returned claim by completely and correctly filling in the claim form.
The following items, if missing or incorrect, will delay processing of your claim or even result in a request for re-submission:
- Subscriber's name
- Subscriber's member ID number (11-digits)
- Patient's name and date of birth
- Date of service
- UHA group number (4-digits)
- Name of referring physician for claims from laboratories, radiologists, and consultants
- Date, place, and cause of injury
- Descriptive diagnosis and ICD-9 code
- Descriptive procedures and CPT code
- Provider's billing name and address
- Provider or agent's signature
- Supportive data for modifiers, e.g. after-hours modifier - claim should have time listed
- Provider Identification Number (PIN)
- Federal tax ID number
Avoid the following possible claims(s) denials:
- Claim submitted with Modifier -25 or -57?*
- Tip: Submit your claims with supporting documentation indicating a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.
- Claim submitted with Modifier -59?*
- Tip: Submit your claim with supporting documentation indicating the service was distinct or independent from other service(s) performed on the same day.
- Claim submitted with duplicate CPT codes?*
- Tip: Submit your claim with supporting documentation indicating the service(s) is not a duplicate.
- UHA is secondary insurance carrier?*
- Tip: Submit your claim with primary insurance carrier's EOB (Explanation of Benefits)/RA (Remittance Advice).
*You may also apply this information for previously denied claims resubmitted for reimbursement reconsideration
Important note: UHA will not accept ICD-10 diagnosis codes until October 1, 2015. However, UHA has begun accepting the new CMS-1500 claim form. The last day to submit the old CMS-1500 claim form is September 30, 2014. You may also refer to our notice regarding the new CMS 1500 claim form. Please contact Customer Services if you require further assistance.
Box 21 – DIAGNOSIS OR NATURE OF ILLNESS OR INJURY – ICD INDICATOR
Use the ICD-9 or ICD-10 code for each current diagnosis applicable to that visit. Do not put any description for each diagnosis code. The new form requires that codes be entered in the correct order following the alphabetical reference numbers (A-L) codes are entered left to right (alphabetical order), 4 codes per row, and up to 3 rows. NOTE: This is different from the old CMS form where only up to 4 codes can be entered and according to the numerical order.
UHA recommends that the diagnosis reference numbers (A-L) be used in COLUMN 24E to correspond with the services.
“ICD IND” Use this space to indicate if the diagnosis codes being used are ICD-9 or ICD-10 codes. An indicator of “9” would represent ICD-9 codes and a “0” indicator would represent ICD-10. This is a required field.
Quick Tips - Addressing Returned / Denied Claims
Here are three common reasons a claim may be denied and some helpful tips to get your claims paid without delay:
- Denial Reason: "Duplicate claim":
- Check other claims to see if the service was paid on another claim;
- If the service in question was not paid on another claim:
- Do NOT resubmit the same claim.
- Instead, submit the Provider Claims Action Request form with clinical notes.
- Denial Reason: "Exceeded timely filing":
- Submit the Timely Claim Filing Waiver Form for providers with supporting documentation.
- Denial Reason: "No Prior Authorization on file":
Acceptable reasons for timely filing waivers:
- Claim submission within 12 months from date of service
- Claim submission within 12 months from date of denial
- Claim submission within 12 months from newborn enrollment
- Claim submission within 12 months from primary carrier’s payments
- Claim submission within 12 months of third party liability payer exhaust denial (must provide dated denial)
If none of the above reasons apply, a Claim Filing Waiver Form may be submitted with one of the following documents that support attempts of earlier claims submissions:
- Copy of the electronic claim denial/rejection notification
- Dated correspondence from UHA with claim information detailing why claim was rejected
- Dated confirmation of claim receipt
When requesting a waiver, please use the Timely Claim Filing Waiver Form.
If you have any questions regarding timely filing, please contact Customer Services at (808) 532-4000, extension 351, from Oahu or (800) 458-4600, extension 351, from the neighbor islands.
- What should you do if you are asked to resubmit a claim with notes?
- Submit a paper claim with medical notes attached and write "Resubmission" at the top right hand corner.
- What should you do if there is a denial on your claim that you disagree with?
- Complete and submit a "Claim Reconsideration Request" form along with your medical notes.
- Do not submit a claim with the "Claim Reconsideration Request" form to avoid a duplicate claim denial.
- What should you do if you would like to make a correction on a previously submitted claim?
- Submit a paper claim and write the words "Corrected Claim" at the top right hand corner.
- Please ensure that the corrected claim matches your original claim with the exception of the area(s) that is being corrected.
See example below:
(Line 1: CPT changed to 99213 / Lines 2 & 3 identical to original claim)
The forms and documents on this page require the free Adobe Acrobat Reader. Please download Adobe Reader