Frequently Asked Questions

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Benefit Coverage

Can I change between UHA benefit plans at any time?

Once you select a plan, you must remain in the plan until your group’s next open enrollment period. Open enrollment period occurs annually. See your company’s Human Resources Director for your open enrollment period.

Does UHA have any pre-existing condition clause?

UHA does not have any pre-existing condition clause.

What do I do if I have a pre-existing condition and would like to continue my treatment plan?

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 at 808-532-4006.

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.

Who is responsible for notifying UHA regarding hospital outpatient or inpatient services?

Participating physicians are responsible because they have the necessary information to complete the notifications, 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.

Who do I notify if I have an urgent authorization request?

Contact Health Care Services at 808-532-4006.

My physician has referred me to a specialist on the mainland. May I receive coverage for these services?

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.

Contact Health Care Services with any questions at 808-532-4006. For more information, please view Receiving Care Outside of Hawaii.

I would like to get a second opinion from a mainland provider. Is it a covered benefit?

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.

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 at 808-532-4006.

Claims Submission

How do I submit claims for medical services received from a non-participating provider?

Any claim or receipt for services submitted to UHA for payment must include the following information and can be sent by mail or fax.

Step 1: Make sure your claim has all required information.

  • Your member identification number from your identification card; if not available, patient’s date of birth is required
  • The provider’s full name and address
  • The patient’s name and address
  • The date(s) services were received
  • The charge for each service (in U.S. currency)
  • A description of each service (UHA uses the nationally accepted CPT-4 and HCPCS procedure codes)
  • A diagnosis or type of illness or injury (UHA uses the nationally accepted ICD-10 diagnostic codes)
  • If applicable, information about any other health coverage you have

If submitting claims from providers in a foreign country:

  • All claims submitted from a foreign country for reimbursement must be translated into English.
  • If the bill was paid with foreign currency, the rate of exchange applicable on the date of service must also be supplied to UHA.

The above information must be from your provider (statements you prepare, cash register receipts, receipt of payment notices or balance due notices cannot be accepted). Without the required information, claims are not eligible for benefits.

Step 2: Send your claim and required documentation to UHA by mail, fax or online.

Claims should be submitted to us as soon as possible after the date of service. All claims for payment for services must be filed with UHA within one year of the date of service. UHA will not make payment on any claim received more than one year after the date on which you received the service.

Submit by mail or fax:

  • Via Mail: 700 Bishop Street, Suite 300, Honolulu, HI 96813
  • Via Fax: 866-572-4393

Please note that UHA is not responsible for the loss of any receipts. Always keep a copy of everything submitted with your claims.

For assistance with submitting your claim, call Customer Services at: 808-532-4000, Toll free: 1-800-458-4600.

Explanation of Benefits (EOB)

What is an EOB?

An Explanation of Benefits (EOB) is generated after your claim has been processed. The EOB tells you how much your health plan covered. It describes how we processed the claim, including the services performed, the amount charged, our eligible charge, the amount we paid, and the amount, if any, that you owe under the health plan benefits. It is not a bill. If you have a financial obligation to providers, they will usually send you a bill. If we denied the claim or any part of it, the EOB will provide an explanation for the denial.

The EOB covers a one-month period. The EOB month is when the claim was processed, not necessarily the month you received the service.

How do I view my EOB(s) online?

  1. Go to uhahealth.com, click “Log In” at the top of the page, then click “Member log in.”
  2. If you have an Online Member Services account: Enter the username and password you used to create your account to log in to Online Member Services.
  3. If you do not have an account: Please register here (make sure to have your UHA member ID number ready), then log in.
  4. Click on “EOB” in the menu at the top of the page. EOBs are listed by month with the newest at the top.

You will need Adobe Reader to view your EOBs. Download Acrobat Reader free of charge at get.adobe.com/reader.

I have a young child that recently used their benefits. Where is their EOB?

Each family member will receive an EOB electronically through their individual Online Member Services account. You or your family member will need to log in to your individual accounts to review your EOB(s). If you do not have an Online Member Services account, please register here to create one.

Why did I get notified of a family member's EOB?

You and the family member have the same email address. Because of this, your family member will also be notified when you have an EOB available. If you wish, you may set up your own email address so only you will be notified when an EOB is available.

Claim Reconsideration and Appeal

Can a claim be reconsidered?

Yes, claims can be reconsidered for a variety of reasons. Please contact Customer Services for assistance.

What if I am not satisfied with the decision of my reconsidered claim?

If you are not satisfied with our response to your concern, or do not wish to request informal reconsideration, you must 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 Appeals

You may request an expedited appeal if the standard time (30 or 60 days, as set forth above) for completing an appeal would:

  • seriously jeopardize your life or health,
  • seriously jeopardize your ability to gain maximum functioning, or
  • subject you to severe pain that cannot be adequately managed without the care or treatment requested

You may make your request for expedited appeal by calling Health Care Services at 808-532-4006. If a health care provider with knowledge of your condition makes a request for an expedited appeal on your behalf, we do not require a written authorization from you.

Who can request an appeal?

You or your authorized representative may request an appeal. Those include:

  • any person you authorize to act on your behalf as long as you follow our procedures. This includes filling out a form with us
  • a court-appointed guardian or agent under a health care proxy
  • 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.

What if I am still not satisfied with the final decision of my appeal?

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:

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

What is the difference between "participating" and "non-participating" providers?

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.

How can I find out if my healthcare provider is a participating provider?

Participating providers can be found in our Care Provider Search tool on the UHA website here.

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.

How do I get reimbursed for services received from a non-participating provider?

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 non-participating benefit level and based on UHA’s eligible charge. At our sole discretion, however, we will make payments directly to non-participating facilities for 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

See this related question for specific steps on how to submit your claim from a non-participating provider to UHA.

How do I get reimbursed for emergency services received in a foreign country?

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 if they meet appropriate criteria.

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
  • Diagnosis
  • 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.

See this related question for specific steps on how to submit your claim from a non-participating provider to UHA.

If I should become injured or ill while traveling within the U.S., will my medical care be covered?

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. Through our relationship with UnitedHealthcare, you have access to UnitedHealthcare’s Options PPO Network, and seeing a UnitedHealthcare participating provider can significantly limit your out-of-pocket expenses. We recommend checking to see if there is a UnitedHealthcare participating provider 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.

If I am attending college, working, or living on the mainland, or on COBRA, how do I facilitate my medical care?

Notify Employer Services regarding your out-of-state address.

You also have access to UnitedHealthcare’s Options PPO Network, a mainland network of providers, and one of the nation’s largest and most respected national PPO networks. Selecting a UnitedHealthcare participating provider is a benefit to you and provides a significant cost saving over a non-participating provider.

Enrollment

Who is considered a dependent?

The following are considered eligible dependents:

  • The spouse or Civil Union Partner of the employee
  • Dependent children up 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 and have a verifiable disability
  • 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.

How do I add my newborn child, adopted child, newlywed spouse or Civil Union Partner to my plan?

To enroll your newborn child, adopted child, newlywed spouse or Civil Union Partner, 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.

I lost my member ID card. How do I get a new one?

You may either contact Customer Services, email us via our online form, complete and fax a Request for Member Identification Card form or visit our Member Portal where you can register and print a temporary card.

How long does it take to get a member ID card?

Member ID cards are usually mailed within five to seven business days after an enrollment or request for a card is received.

Will my dependents receive member ID cards?

The subscriber will receive two ID cards. The cards list the name of the subscriber (employee) and each dependent’s name. Additional ID cards can be requested through Customer Services at 808-532-4000.

Out of State Coverage and U.S. Mainland Provider Network*

What can members expect from UnitedHealthcare’s Options PPO Network?

UHA’s primary service area and provider network remains in Hawaii where the best care for your needs is likely to be right here at home. However, when you or your ‘ohana do travel away from Hawaii to temporarily visit the U.S. mainland—whether that’s for study, travel or work—UHA has our members covered for emergency medical care.

Through our relationship with UnitedHealthcare, UHA offers access to quality medical care from UnitedHealthcare’s extensive U.S. mainland network of providers, as well as online tools and resources to help members find the right care during their travels.

Does the UnitedHealthcare (UHC) network include international healthcare coverage and benefits?

No. Through the UHA Health Insurance benefit plan, members have access to the UnitedHealthcare Options PPO Network, which is available only on the U.S. mainland.

How do members find a provider in the UnitedHealthcare network when on the mainland?

Use the UnitedHealthcare online provider directory at UHAHealth.com/mainlandnetwork.

By using UnitedHealthcare’s mainland provider network, our members will have access to quality health care resources to support all of their health-related needs while on the U.S. mainland.

Note: when at home in Hawaii, members utilize the UHA provider network. To find a convenient provider in Hawaii, go to UHAhealth.com and click on Find Care Providers & Drugs at the top of the screen or call Health Care Services at 808-532-4006 for assistance locating a provider who is accepting new patients.

How do Complementary and Alternative Medicine (CAM) benefits and services work under the UnitedHealthcare network?

UHA will follow UnitedHealthcare’s network for Chiropractor, Therapeutic Massage Therapy and Acupuncture services. If a provider is participating within the UnitedHealthcare network, the CAM benefits will be covered assuming the services meet UHA’s criteria for payment.

Note: when at home in Hawaii, members utilize the UHA provider network. To find a convenient provider in Hawaii, go to UHAhealth.com and click on Find Care Providers & Drugs at the top of the screen or call Health Care Services at 808-532-4006 for assistance locating a provider who is accepting new patients.

Where is the UnitedHealthcare provider directory located?

Visit UHAHealth.com/mainlandnetwork. Simply search the UnitedHealthcare online provider directory and locate a doctor or facility when on the U.S. mainland.

We created that dedicated online page for members to access UnitedHealthcare’s extensive provider network and quality health care resources to support all their health-related needs while away from home in the event of an emergency or if a dependent is living on the mainland for school.

*Insurance coverage is provided by UHA Health Insurance. The administrative services are provided by United HealthCare Services, Inc.

Express Scripts: General

How does Express Scripts help me manage my medications?

With Express Scripts you have access to pharmacists who have expertise in the medications for high blood pressure, asthma, diabetes or cancer. Pharmacists at Express Scripts can help with questions about your medications. The pharmacists can also advise you how to potentially reduce your medication costs.

When you log into your Member Portal at UHA, either on the website or the mobile site, you can also access your current prescription information with Express Scripts. You may also log in directly to Express Scripts at express-scripts.com or by calling the number listed below.

  • Customers calling about their prescriptions: 855-891-7978
  • Pharmacists (for Rx or PA information): 800-922-1557 or 800-753-2851
  • Providers (for PA): Express PAth

Your doctor can call in a prescription over the phone or enter the information on the website. In most cases, your doctor will get a real-time response.

Do I have to call Express Scripts, or can I call UHA's customer service line?

It is best to contact Express Scripts directly with questions about your copay or out of pocket costs. UHA’s phone lines are also available 8 am to 5 pm, Monday – Friday, except for major holidays. A representative can be reached at 808-532-4000 (or 800-458-4600 from the neighbor islands) at the extensions below:

  • Customer Services: or 800-753-2851 ext. 297
  • Health Care Services: ext. 300
  • Employer Services: ext. 299
  • Premium Billing: ext. 353

Express Scripts: ID Card

How do I get a new or replacement member ID card?

Should you misplace or not receive a new card, you may submit a request via our website or call our Customer Services department at 808-532-4000 or 1-800-458-4600 (from the neighbor islands). Your card will have the following information that your pharmacy needs to process your prescription(s):

RxBin: 003858
RxPCN: A4
RxGroup: NKTA

Please note that your drug plan may be self-insured by your employer or you may not have a drug benefit.

Do I need to show my member ID card at the pharmacy?

Yes. This is very important in order to avoid delays in processing extended or autofill prescriptions, as the pharmacy may not update the information until the member receives a rejection. The key is to give your pharmacist these numbers:

RxBin: 003858
RxPCN: A4
RxGroup: NKTA

These are the same for everyone with UHA drug coverage.

Reimbursement

How do I submit my receipts for prescriptions that I paid for out of pocket?

You may submit your receipts by fax directly to Express Scripts at 877-329-3760. There is a direct member reimbursement form (DMR) located on the Express Scripts website that you may send with your receipts that will ensure timely reimbursement (submit receipts within 90 days from date of purchase).

How do I file a Drug Claim from a Non-Participating Provider?

Non-participating pharmacies may require you to pay for your prescription in full and have you file your claim with UHA. You can submit your receipts for reimbursement via fax to Express Scripts at 877-329-3760. There is a direct member reimbursement form (DMR) located on the Express Scripts website that you may send with your receipts that will ensure timely reimbursement. You should note that the reimbursement is likely to be less than if you used a participating pharmacy.

Express Scripts: Home Delivery

How does extended fill or mail order work?

UHA members may obtain an extended supply of their maintenance medications at most UHA-participating retail pharmacies within the Express Scripts network.

For mail order services, members may enroll in Express Scripts Home Delivery. Manage your prescription orders via a single login using your UHA Online Member Services account. Call 800.282.2881 to contact Express Scripts’ Patient Customer Service if you need help enrolling. Learn more on our Prescription Drugs page.

Express Scripts: Benefits and Coverage

How do I get vaccinations?

You can either get vaccinations at your doctor’s office or at a pharmacy in network.

Why do some drugs need prior authorization (PA)?

If a pharmacist tells you that your prescription needs a PA, your doctor should contact Express Scripts to be sure that drug is right for you. We also need to check if your plan covers the drug. This is similar to when your healthcare plan authorizes a medical procedure in advance.

When a prescription requires a PA, your doctor can call Express Scripts or prescribe a different drug that is covered by the plan. Only doctors can give Express Scripts the information they need to see if the drug is covered. Express Scripts answers PA phone lines 24 hours a day, seven days a week. A decision can be made right away. If the drug is covered, you will pay your normal copayment. If you choose the medication that is not covered, you will pay the full price.

How do I request a rush review?

Your doctor can use eviCore portal online or submit a PA by phone. In most cases your doctor will receive a real-time answer. If approved, you will be able to pick up your medication right away.

What if I disagree with a decision made by Express Scripts?

If you disagree with a decision made by Express Scripts, your doctor may contact UHA’s Health Care Services department Monday-Friday, 8am to 5pm HST to request a peer-to-peer conversation within 30 days of the denial. We will arrange a time for your doctor to speak with our Medical Director or Chief Medical Officer. If you or your doctor would like to submit a written appeal, please follow our appeals process here.

Some drugs are managed under your medical benefits rather than by your pharmacy benefits. Some injectable drugs are reviewed by CareContinuum, an Express Scripts company. If you disagree with a decision made by CareContinuum, please contact them at (866) 877-7042, Monday-Friday, 8am to 5pm EST. With CareContinuum, your doctor will be able to request a peer-to-peer conversation or submit a written appeal.

How will UHA cover my medications if I also have other insurance coverage?

COB (coordination of benefits) claims may be subject to PA, which means if the drug or procedure needs a PA from UHA, even if UHA is the secondary insurer, the PA will still need to be submitted.

Primary insurance coverage applies to the original claim, but the member is responsible for the remaining balance. That amount will come in on a claim to UHA as the secondary insurer. Some examples are listed below:

Note: Primary insurance already paid on the claim, so the COB claim comes to UHA as secondary insurance.

Example #1 $30 patient responsibility

  • $0 deductible
  • $45 UHA Drug Plan
UHA pays $0
Member pays $30
Example #2 $30 patient responsibility

  • $0 deductible
  • $15 Drug Plan copay
UHA pays $15
Member pays $15
Example #3 $500 patient responsibility

  • $0 deductible
  • $15 Drug Plan copay
UHA pays $485
Member pays $15
Example #4 $500 patient responsibility

  • $0 deductible
  • $100 Drug Plan co-insurance
    (20% 4th tier)
UHA pays $400
Member pays $100

Plans P, & S have $200 & $250 drug price limits respectively, which means the coinsurance will hit the “4th Tier 20% coinsurance requirement” if the drugs exceed those amounts.

Definitions

I don't understand the difference between Generic, Preferred Brand and Non-Preferred Brand drugs. Please explain.

  • Generic drugs are the lowest cost drugs; copies of patented Brand name drugs that have the same chemical action as Brand name drugs.
  • Brand medications are either Preferred or Non-Preferred (sometimes referred to as Formulary or Non-Formulary).
  • Preferred Brand drugs have a lower copay than Non-Preferred Brand drugs.
  • Non-Preferred Brand drugs are newer drugs that are usually the most expensive drugs available among them all.

Can you explain what Step Therapy is?

Step therapy is for people who take prescription drugs daily to treat a long-term condition (arthritis, asthma, or high blood pressure). It lets you get treatment at a lower cost. It also helps your employer maintain prescription drug coverage for everyone your plan covers.

In step therapy, medicines are grouped in categories based on treatment and cost.

  • First-line medicines are the first step. They are generic and lower-cost brand-name drugs approved by the U.S. Food & Drug Administration (FDA). They are proven safe, effective and affordable. Step therapy suggests you try these drugs first. In most cases they provide the same health benefits as more expensive drugs, but at a lower cost.
  • Second-line drugs are the second and third steps. These are often brand-name drugs. They are best for patients who don’t respond to first-line drugs. Second-line drugs are the most expensive.

Generic drugs have the same chemicals as the brand-name. They also have the same effect. Though generics may have a different name, color and/or shape, they have been through the same testing as the original drug. They have also been approved by the FDA as safe and effective in the same manner as the original drug.

Unlike manufacturers of brand-name drugs, the companies that make generic drugs don’t spend as much money on research and advertising. As a result, generic drugs cost less than the original brand-name drug and the savings get passed on to you.

The first time you try to fill a prescription that isn’t for a first-line medicine, your pharmacist should explain that step therapy asks you to try a first-line medicine before a second-line drug. Only your doctor can change your current prescription to a first-line drug covered by your plan.

Can you explain what Quantity Limits are?

Quantity limits make sure that you get the right amount of medication and in the least wasteful way. For example, your doctor might have told you to take two 20mg pills each day. If that medication was also available in 40mg pills, our staff would ask the doctor to prescribe one 40mg pill a day instead of two 20mg pills. In addition, if the doctor wrote the original prescription for 30 pills (a 15-day supply), the new prescription for 30 pills would last a full month — resulting in just one copayment, not two.

If the prescription is for a larger quantity, the pharmacist can fill the prescription for the amount that the plan covers or contact the doctor to discuss other options. The pharmacist may increase the strength or get a PA for the quantity originally prescribed.

Transparency in Coverage and No Surprises Act

What is the Transparency in Coverage and No Surprises Act?

Refer to our overview here for details.