FAQs for Members
A. Once you select a plan, you must remain in the plan until your group's next open enrollment period. Open enrollment periods occur annually. See your company's Human Resources Director for your open enrollment periods.
A. Our benefit plans do not limit coverage for pre-existing conditions.
A. If you are a new member to UHA and are currently on a treatment plan, have your physician contact Health Care Services to discuss a treatment program to ensure there is no lapse in your medical services.
Also, ask your Human Resources Director for a UHA Transition Coverage Questionnaire or access it on our Forms and Documents page, under the Employer Forms tab. Completing and submitting this form will ensure continuation of your care during the transition period.
A. Participating physicians are responsible because they have the necessary information to complete the referrals, i.e., diagnosis and procedure codes. If you have elected to
receive your care from a Non-Participating provider, you become primarily responsible for this prior notification to UHA.
A. Your physician must submit an Out-of-State Services Request Form at least 2 weeks in advance.
We advise that you do not make travel arrangements until the review is completed and you and your referring physician receive written confirmation from us that the service will be covered. Benefit coverage information will be provided only after the review is completed. Airfare and lodging are not covered benefits.
A. Providers outside of Hawaii are not contracted with UHA, therefore, non-participating provider benefits will apply. This means UHA will pay only up to our eligible charge for non-participating providers, which is based on our rate for similar services performed in Hawaii. You are responsible for the difference between UHA's payment and the provider's actual charge ("balance billing"), which can be substantial. See your medical benefits guide for the eligible, non-participating provider level amount.
Members are encouraged to obtain their second opinion within the State of Hawaii, which is covered at 100% of the eligible charge. If you are considering out-of-state services, please contact Health Care Services to discuss your options.
Claim Reconsideration and Appeal
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. Appeals 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 How to Initiate An Appeal.
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):
- 1. For an acute or urgent condition; or
- 2. 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. You or your authorized representative may request an appeal. Those include:
- a provider
- a court-appointed guardian or agent under a health care proxy, or other person whom you designate to us in writing to represent you on your appeal (you must provide us documentation of any representative capacity with your appeal)
- a person authorized by law to provide substituted consent for you or to make health care decisions on your behalf
- a family member or your treating health care professional if you are unable to provide consent
To designate an authorized representative to act on your behalf with UHA, you must submit to UHA the Authorized Representative Form. This form must be completed and returned to UHA's Appeals Coordinator before an appeal request can be considered.
A. If you are not satisfied with the final decision of the UHA Appeals Committee, you have the following external appeal rights:
If you disagree with an appeals decision regarding medical necessity, appropriateness, or experimental or investigational services, you may request external review of the decision by an Independent Review Organization (IRO) assigned by the State of Hawaii Insurance Commissioner. This request must be submitted in writing to:
Hawaii Insurance Division
Attn.: Health Insurance Branch – External Appeals
335 Merchant Street, Room 213
Honolulu, HI 96813
Your request must include the following documents:
- Request for External Review by IRO
- External Review HIPAA Authorization Form
- Disclosure for Conflicts of Interest Evaluation
If you do not elect to request review by an IRO, or if you disagree with an appeal of any other decision, your options for external review vary depending on your plan. For more information, please view If You Disagree With Our Final Appeals Decision.
Participating vs. Non-participating
A. Participating providers have a signed contract with UHA, and receive reimbursement of eligible charges directly from UHA. From a member perspective, only a co-payment, deductible, applicable state excise tax, co-insurance, and payment for non-covered items (if any) may be required at the time of service.
All other providers, without signed UHA contracts, are considered non-participating providers. Non-participating providers may collect their full charge(s) from the member at the time of service.
A. Participating providers can be found in our Provider Directory-you may request a hard copy from Customer Services. You may also search for participating providers by using the Find a Provider tool on the UHA website at: https://uhahealth.com/providers/search
UHA's directories are subject to change. For verification of the most current provider participation status, call Customer Services at: 532-4000, Toll free: (800) 458-4600
A. Members are responsible for the total amount billed, usually at the time of service. UHA will make payments for covered services directly to the subscriber of the plan. Reimbursements will be at the UHA eligible, non-participating benefit level. At our sole discretion, however, we will make payments directly to non-participating hospitals for inpatient services. Therefore, the Member is responsible for the difference between the billed charges and the amount of UHA's reimbursement, including any applicable co-payments, co-insurance, or deductible.
UHA will not accept invoices or receipts as claim forms for services rendered in the U.S.
* Standard claim forms are:
- Inpatient/Outpatient facilities - UB-04 CMS-1450
- Professional/Other services - CMS-1500 (08-05)
- Prescription drugs - DAH 3PT-1000
A. Traveling to a foreign country for the purpose of receiving services is not a covered benefit, even if referred by your physician. Only emergency medical services performed outside the U.S. will be covered.
Claims for services rendered by a foreign provider must be fully translated to English and must contain:
- Patient's name
- Patient's date of birth
- Procedures done with dates of service and charges (listed separately)
- Name and address of the provider of service
- Name and address of the facility where services were rendered
- Your receipt of payment made, converted to U.S. Dollars and the rate of exchange on the dates of service
In certain instances, we may require additional documentation such as admission and discharge summaries, or daily hospital records.
A. Yes. If you become injured or ill while traveling within the U.S., any emergency care, urgent care, or hospitalization will be covered according to your plan benefits. We have an agreement with a mainland network called First Health Network, and seeing a First Health participating provider can significantly limit your out-of-pocket expenses. We recommend checking to see if there is a First Health participating facility in the area of travel.
Treatment for a condition which occurred or was diagnosed before your trip will be subject to the same prior authorization requirements as any non-emergent treatment outside of the State of Hawaii. Contact Health Care Services with any questions.
A. Notify Employer Services regarding your out-of-state address.
You also have access to First Health Network, a mainland network of providers, and one of the nation's largest and most respected national PPO networks. Selecting a First Health Network participating provider is a benefit to you and provides a significant cost saving over a non-participating provider.
A. The following are considered eligible dependents:
- The spouse of the employee
- Dependent children to age 26 regardless of marital status, enrollment in school, or residency
Please note: Spouses and children of adult dependents do not qualify for this coverage
- Unmarried children who are disabled
- Other categories of dependents are subject to the provisions of the employer's Group Service Agreement. Please consult with your employer for questions about dependent eligibility.
- Civil Union Partner
A. To enroll your newborn child, adopted child, or newlywed spouse, complete a Member Enrollment form. The form along with the appropriate documents should be submitted by the group administrator to UHA. Additions to your health plan must be enrolled within 31 days of birth, adoption, marriage or civil union.
A. An employer can add a new employee anytime with the Member Enrollment form within 31 days of the date the employee becomes eligible for coverage. Coverage will always be effective on the first day of the month following enrollment.
A. An employer can terminate an employee's coverage by using the Member Termination form. Employee eligibility under most medical benefits programs terminates on the last day of the month in which employment ends. Mid-month terminations or retroactive terminations will not be accepted.
A. Member ID cards are usually mailed within five days after an enrollment or request for a card is received.
A. The subscriber will receive two ID cards. The cards list the name of the subscriber (employee) and each member's name. Additional ID cards can be requested through Customer Services at 808-532-4000.