TimelyFilingForm

Online Provider Timely Claim Filing Waiver Form: Please fill out the form and click Submit Form

Complete the online form below.

For questions please call Customer Services at 522-2268, or 800-458-4600, extension 302, from the neighbor islands.

Rendering Provider Name:
Patient’s Name: Patient ID #:
Date of Service: Claim #:
Contact Name:
Contact E-Mail: Contact Phone:

Reason for requesting a timely filing waiver:

Please submit any of the following documents listed below to support your request.
Please put a checkmark next to documents you will upload. You will be prompted to upload documents after you click the Submit Form button.:

Copy of Primary Carrier’s EOB
Copy of denial or exhaust letter from Third Party Liability (TPL)
Copy of HCFA 1500/UB04 claim (if claim was never submitted)
Copy of HCFA 1500/UB04 claim with date stamp or proof of electronic submission (if claim was submitted, but never received)
Additiional documentation that provides proof of timely filing attempts such as: certified mail receipt, documented timeline of follow-up with payer or proof of electronic claim submission.

By checking this box I affirm that I am authorized on behalf of my organization to submit this form. I have used all reasonable diligence in submitting the information in this form, and I certify that the information submitted is corrrect.
The parties agree that this form and all notices and disclosures made or given in connection with this form may be created, executed, delivered and retained electronically. As such, the parties agree that this form and any related documents may be signed electronically, and that the electronic signatures appearing on ths form or any related documents shall have the same legal effect for all purposes, including validity, enforceability and admissibility, as a handwritten signature.
By signing and submitting this form, Provider confirms the accuracy and completeness of the information provided on this form and any attachments, and agrees to be bound by the terms of the UHA Participating Provider Agreement and UHA’s Provider Handbook, which terms shall become effective upon UHA sending a letter giving Provider notice of approval of addition. Provider also confirms his/her intent to be bound by the dispute resolution process described in UHA’s Participating Provider Agreement, described above, which includes binding arbitration of all disputes.