Provider Claim Submission
Submitting Medical Claims ElectronicallyIMPORTANT: As of October 1, 2015, all HIPAA-covered entities are required to use ICD-10 codes for services on or after that date. Please see our FAQs for more information.
We are committed to the timely* and accurate processing of your claims, and encourage claim submission through electronic data interchange (EDI). There are three ways to submit medical claims electronically. You may connect either directly to UHA, submit your claims through a clearinghouse that has a connection with UHA, or through the Hawaii Xchange online service.All methods are quick to set up and providers who submit claims electronically will enjoy:
- Faster processing and reimbursement of claims**
- Proof of timely submission through electronic acceptance reports
- Reduced number of lost claims
- Reduced costs associated with labor, paper, and postage for claims
Send directly to UHA
You must be able to generate a HIPAA 837 formatted claim transaction file to send directly to UHA. In addition, you are required to submit one of the EDI forms below.
For Professional Claims, please fill out the following form:
For Institutional Claims, please fill out the following form:
If you wish to receive and Electronic Remittance Advice (835), please fill out the following form:
NOTE: The forms above are only for direct claims submission. If submitting through a clearinghouse, please obtain the appropriate enrollment forms from the clearinghouse.
Send through a clearinghouse that has a connection with UHA
You will need to contact your clearinghouse to obtain specific instructions on how to submit your claims to UHA. You must be enrolled and approved to submit claims through your clearinghouse. You will need to contact your clearinghouse to obtain the UHA enrollment forms.
Send through Hawaii Xchange Direct Data Entry Claim Submission
The Hawai’i Xchange is a free service for providers to manage their data, operational, reporting, inquiry, and maintenance needs. The benefits of Hawai’i Xchange are as follows:
- Service is free for providers with no monthly setup or connection fees
- Service is web-based, so no software purchase is required
- You connect directly to UHA for uploading claims
- Claims are submitted online to minimize paperwork and processing time
- Rejected DDE claims can easily be edited for resubmission to UHA
- Non-electronic formats (i.e., paper-based claims) are easily transformed into electronic format (DDE)
- Print files and proprietary formats are easily translated into X12 format
- Remittances (835) can be received and viewed (online)
- Pre-formatted and custom reports for your practice can be accessed (online)
- Enroll now and get started with Hawaii Xchange
* Medical claims must be filed within one year of the date of service to ensure the claim is payable. This requirement also applies when UHA is your patient’s secondary insurance carrier. An exception may be made to the one-year filing time limitation when UHA is secondary to Medicare. Timely filing of claims is the provider’s responsibility. You may not collect payment from the member for any covered services after the one-year claims submission deadline has expired.
** A clean claim means no missing data fields and HIPAA compliant transaction set.
Avoiding Returned 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 code
- Descriptive procedures and CPT code
- Charges, per line item
- 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
Requesting Reconsideration of a Claim
If you believe a claim should not have been denied, or disagree with the amount of the payment, you may request that we review the claim. Requests for review must be made within one year of the date the claim was paid or denied. We will review your request and get back to you within two business days. We will then provide you with an estimate of the time it will take to resolve your issue. We may request additional written information from you (e.g., additional diagnostic information, emergency notes or an operative report) to aid in the review process.
If you need to request reconsideration of a claim, you can refer to the Claim Reconsideration and Appeals section of our FAQs.
Upon review completion, one of two things may happen:
We will reprocess the claim (and send you a new Remittance Advice Summary), or
We will inform you in writing why we believe our original determination was correct. If the matter is not resolved to your satisfaction, you may appeal our decision to our Appeals Committee.
For more information on how to file an appeal or for general claims information, please refer to our Provider Handbook.
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