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UnitedHealthcare Community Plan Hawaii Providers

Aloha and welcome to UnitedHealthcare Community Plan!

Here, you will find the information and links you need to conduct business with UHC Community Plan.  Please choose your topic of interest, by selecting one of the navigation buttons on the left-hand side of the page, or select one of the topics or products below to view the details.

Contact Us - QUEST Integration (PDF 75.12 KB)

Report Health Care Fraud, Waste and Abuse: 844-359-7736 or uhc.com/fraud

 

HIPAA Claim Edits

UnitedHealthcare applies HIPAA edits to professional (837p) and Institutional (837i) claims submitted electronically. Visit the EDI Claim Edits page for more information including a complete list of edits, edits related to ICD-10 codes and applicable payers. Claims that reject for HIPAA edits will appear on a clearinghouse level report, enabling you to Identify and correct rejected Information prior to UnitedHealthcare receiving the claim.

 

Changes and Updates to Service Delivery

Any changes or updates to service delivery will be communicated via this portal under the Section "Changes and Updates to Services Delivery," Provider Newsletters or Bulletins, Provider Education & Training Sessions and other forms of communication.  

 

 

Prior Authorization

QUEST Integration Prior Authorization Request Form (PDF 296.87 KB)

HI Medicare DSNP Prior Authorization Request Form (PDF 577.61 KB)

UnitedHealthcare Community Plan
UnitedHealthcare Community Plan Prior Authorization HI - Effective 10/1/2017 (PDF 195.47 KB)

UnitedHealthcare Medicare Solutions and United Healthcare Community Plan
UnitedHealthcare Medicare Prior Authorization Requirements - Effective 10/1/2017 (PDF 286.74 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements - Effective 7/1/2017 (PDF 300.09 KB)

UnitedHealthcare Community Plan Prior Authorization HI - Effective 7/1/2017 (PDF 194.84 KB)

UnitedHealthcare Community Plan Prior Authorization HI - Effective 4/1/2017 (PDF 192.85 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements - Effective 5/1/2017 (PDF 299.55 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements -  Effective 1/1/2017 (PDF 306.96 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan-Medicare Notification/Prior Authorization Requirements - Effective 4/1/2017 (PDF 300.79 KB)

UnitedHealthcare Community Plan Prior Authorization HI - Effective 1/1/2017 (PDF 190.49 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan Notification / Prior Authorization Requirements -  Effective 10/1/2016 (PDF 277.31 KB)

UnitedHealthcare Community Plan Prior Authorization HI - Effective 10/1/2016 (PDF 195.36 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan Notification/Prior Authorization Requirements - Effective 7/1/2016 (PDF 266.74 KB)

UnitedHealthcare Community Plan Prior Authorization HI - Effective 7/1/2016 (PDF 193.19 KB)

UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan Notification/Prior Authorization Requirements - Effective 5/1/2016 (PDF 251.42 KB)

UnitedHealthcare Medicare Solutions Notification/Prior Authorization List - Effective 1/1/16 (PDF 249.77 KB)

Advanced Notification Requirements for HI - Effective Jan. 15, 2015 (PDF 489.67 KB)

 

Medical Injectables

Specialty pharmacy medications covered on the Medical Benefit may be provided through a variety of channels – home infusion provider, outpatient facility, physician, or specialty pharmacy.

Specialty pharmacy medications covered under the member's medical benefit may be obtained through various sources ‒ home infusion providers, outpatient facilities, physicians or specialty pharmacy.

If you don't want to buy and bill a specialty pharmacy medication covered under the member's medical benefit, you may order it through one of the following network specialty pharmacies:

Network Specialty Pharmacy

Phone Number

BriovaRx

866-815-5338

BioScrip (offers nursing services)

• also serves as a national home infusion provider for medical benefit medications

866-788-7710

The following specialty pharmacies also provide certain types of specialty medications:

Network Specialty Pharmacy

Medication Category

Phone Number

Accredo (nursing services)

Enzyme Deficiency

Gaucher's Disease

Immune Globulin

Pulmonary Hypertension

800-803-2523

 

Option Care (nursing services)

Cardiovascular/Heart Failure

Enzyme Deficiency

Gaucher's Disease

Hemophilia

Immune Globulin

Makena

866-827-8203

CVS Caremark Specialty Pharmacy

Pulmonary Hypertension

800-237-2767


Coverage of a requested medication depends on the member’s benefit, and availability of a specific drug from a network specialty pharmacy may vary.

Upon request, a specialty pharmacy can deliver the medication to your office or another site such as a member’s home.

Medications obtained through a specialty pharmacy will be directly billed to the patient’s health plan.

 

UnitedHealthcare Community Plan Medical & Drug Policies and Coverage Determination Guidelines

UnitedHealthcare has developed Medical Policies, Medical Benefit Drug Policies and Coverage Determination Guidelines to assist us in administering health benefits. These policies and guidelines are provided for informational purposes, and do not constitute medical advice.
View the guidelines

UnitedHealthcare Medicare Advantage Coverage Summaries

For policy guidance for Medicare Advantage plan members, view the UnitedHealthcare Medicare Advantage Coverage Summaries Manual and corresponding policy update bulletins here

Integrity of Claims, Reports, and Representations to the Government

UnitedHealth Group requires compliance with the requirements of federal and state laws that prohibit the submission of false claims in connection with federal health care programs, including Medicare and Medicaid. 
View our policy (PDF 38.15 KB).

Disclaimer

If UHG policies conflict with provisions of a state contract or with state or federal law, the contractual / statutory / regulatory provisions shall prevail. To see updated policy changes, select the Bulletin section at left.