Chapter 2: Care Provider Standards & Policies


You can’t refuse an enrollment/assignment or disenroll a member or discriminate against them solely based on age, sex, race, physical or mental handicap, national origin, religion, type of illness or condition. You may only direct the member to another care provider type if that illness or condition may be better treated by someone else.

Communication between Care Providers and Members

The UnitedHealthcare Community Plan Agreement is not intended to interfere with your relationship with members as patients or with UnitedHealthcare Community Plan’s ability to administer its quality improvement, utilization management or credentialing programs. Instead, we require communication between PCPs and other participating care providers. This helps ensure UnitedHealthcare Community Plan members receive both quality and cost-effective health services.

UnitedHealthcare Community Plan members and/or their representative(s) may take part in the planning and implementation of their care. To help ensure members and/or their representative(s) have this chance, UnitedHealthcare Community Plan requires you:

  1. Educate members, and/or their representative(s) about their health needs.
  2. Share findings of history and physical exams.
  3. Discuss options (without regard to plan coverage), treatment side effects and symptoms management. This includes any self-administered alternative or information that may help them make care decisions.
  4. Recognize members (and/or their representatives) have the right to choose the final course of action among treatment options.
  5. Collaborate with the plan care manager in developing a specific care plan for members enrolled in High Risk Care Management.

Provide Official Notice

Write to us within 10 calendar days if any of the following events happen:

  1. Bankruptcy or insolvency.
  2. Indictment, arrest, felony conviction or any criminal charge related to your practice or profession.
  3. Suspension, exclusion, debarment or other sanction from a state or federally funded health care program.
  4. Loss or suspension of your license to practice.
  5. Departure from your practice for any reason.
  6. Closure of practice.

Call Provider Services at 888-980-8728 or email

When we are notified of a provider’s exclusion from Medicare or Medicaid, we send them a letter with the date that they will be removed from our contract provider’s list. Except for post-stabilization, emergency, and urgently needed care, no payments will be made after that effective date. Members are notified of the provider’s status so they can choose a new care provider.

We immediately terminate any care provider(s) or affiliated care provider(s) whose owners, agents, or managing employees are found to be on the State or Federal exclusion list(s), including denial of credentialing for fraud related concerns, as they occur. If DHS requires removal of a care provider from its network, we remove that care provider from our network.

Care providers are also prohibited from employing or contracting with an individual who is excluded from participation in Medicaid, or with an entity that employs or contracts with such an individual, for the provision of health care, utilization review, medical social work or administrative services.

Upon reinstatement by DHS, the care provider is responsible for notifying us and applying for reinstatement.

Transition Member Care Following Termination of Your Participation

If your network participation ends, you must transition your UnitedHealthcare Community Plan members to timely and useful care. This may include providing services for a reasonable time at our in-network rate. Provider Services is available to help you and our members with the transition.

Arrange Substitute Coverage

If you cannot provide care and must find a substitute, arrange for care from other UnitedHealthcare Community Plan care providers and care professionals.

For the most current listing of network care providers and health care professionals, review our care provider and health care professional directory at

Administrative Terminations for Inactivity

Up-to-date directories are a critical part of providing our members with the information they need to take care of their health. To accurately list care providers who treat UnitedHealthcare Community Plan members, we:

  1. End Agreements with care providers who have not submitted claims for UnitedHealthcare Community Plan members for one year and have voluntarily stopped participation in our network.
  2. Inactivate any tax identification numbers (TINs) with no claims submitted for one year. This is not a termination of the Provider Agreement. Call UnitedHealthcare Community Plan to reactivate a TIN.

Changing an Existing Tin or Adding a Health Care Provider

Please complete and email the Care Provider Demographic Information Update Form and your W-9 form to the address listed on the bottom of the form.

Otherwise, complete detailed information about the change, the effective date of the change and a W-9 on your office letterhead. Email this information to the number on the bottom of the demographic change request form.

Updating Your Practice Information

If you need to update your practice in any way, such as update your Tax Identification number, or add a new provider to your group, please call Provider Services Call Center 888-980-8728 or email

After-Hours Care

Life-threatening situations require the immediate services of an emergency department. Urgent care can provide quick after-hours treatment and is appropriate for infections, fever, and symptoms of cold or flu.

If a member calls you after hours asking about urgent care, and you can’t fit them in your schedule, refer them to an urgent care center.

Admitting Privileges

You must have admitting privileges to at least one in- network general acute care hospital on the island of service. For the island of Hawai’i, it needs to be on the same side of the island- east or west.

Participate In Quality Initiatives

You must help our quality assessment and improvement activities. You must also follow our clinical guidelines, member safety (risk reduction) efforts and data confidentiality procedures.

UnitedHealthcare Community Plan clinical quality initiatives are based on optimal delivery of health care for particular diseases and conditions. This is determined by United States government agencies and professional specialty societies. See Chapter 10 for more details on the initiatives.

Provide Access to Your Records

You must provide access to any medical, financial or administrative records related to services you provide to UnitedHealthcare Community Plan members within 14 calendar days of our request. We may request you respond sooner for cases involving alleged fraud and abuse, a member grievance/appeal, or a regulatory or accreditation agency requirement. Maintain these records for six years or longer if required by applicable statutes or regulations.

Performance Data

You must allow the plan to use care provider performance data.

Comply With Protocols

You must comply with UnitedHealthcare Community Plan’s and Payer’s Protocols, including those contained in this manual.

You may view protocols at

Office Hours

Provide the same office hours of operation to UnitedHealthcare Community Plan members as those offered to commercial members.

Protect Confidentiality of Member Data

UnitedHealthcare Community Plan members have a right to privacy and confidentiality of all health care data. We only give confidential information to business associates and affiliates who need that information to improve our members’ health care experience. We require our associates to protect privacy and abide by privacy law. If a member requests specific medical record information, we will refer the member to you. You agree to comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and associated regulations. In addition, you will comply with applicable state laws and regulations.

UnitedHealthcare Community Plan uses member information for treatment, operations and payment. UnitedHealthcare Community Plan has safeguards to stop unintentional disclosure of protected health information (PHI). This includes passwords, screen savers, firewalls and other computer protection. It also includes shredding information with PHI and all confidential conversations. All staff is trained on HIPAA and confidentiality requirements.

Follow Medical Record Standards

Please reference Chapter 9 for Medical Record Standards.

Inform Members of Advance Directives

The federal Patient Self-determination Act (PSDA) gives patients the legal right to make choices about their medical care before incapacitating illness or injury through an advance directive. Under the federal act, you must provide written information to members on state law about advance treatment directives, about members’ right to accept or refuse treatment, and about your own policies regarding advance directives. To comply with this requirement, we inform members of state laws on advance directives through Member Handbooks and other communications. We provide an Aging with Dignity Pamphlet, “Five Wishes,” to help members determine their end of life care. Members can find Five Wishes and Hawai’i Provider Orders for Sustaining Treatment (POLST) forms for their use. The Kokua Mau website has information on advance care planning at You can also obtain copies by calling 888-980-8728.

Your Agreement

If you have a concern about your Agreement with us, send a letter with the details to the address in your contract. A representative will look into your complaint. If you disagree with the outcome, you may file for arbitration. If your concern relates to certain UnitedHealthcare Community Plan procedures, such as the credentialing or care management process, follow the dispute procedures in your Agreement. After following those procedures, if one of us remains dissatisfied, you may file for arbitration.

If we have a concern about your Agreement, we’ll send you a letter containing the details. If we can’t resolve the complaint through informal discussions, you may file an arbitration proceeding as described in your Agreement. Your Agreement describes where arbitration proceedings are held.

If a member asks to appeal a clinical or coverage determination on their behalf, follow the appeal process in the member’s benefit contract or handbook. You may locate the Member’s Handbook at

Also reference Chapter 12 of this manual for information on Provider Claim Disputes, Appeals and Grievances.

Comply with the following appointment availability standards:

Primary Care

PCPs should arrange appointments for:

  • After-hours care phone number: 24 hours, seven days a week
  • Emergency care: Immediately or referred to an emergency facility
  • Urgent care appointment: within 24 hours
  • Pediatric sick visits: within 24 hours
  • Adult sick visits: within 72 hours
  • Routine care appointment: within 21 calendar days
  • Physical exam: within 180 calendar days
  • EPSDT appointments: within six weeks
  • New member appointment: within 30 calendar days
  • In-office waiting for appointments: not to exceed one hour of the scheduled appointment time

Specialty Care

Specialists should arrange appointments for:

  • Routine appointment type: within four weeks of request/referral

Behavioral Health

Behavior health care providers should arrange appointments for:

  • Care for non-life-threatening emergencies: within six hours
  • Urgent care: within 48 hours
  • Routine visits: within 10 business days

Prenatal Care

Prenatal care providers should arrange OB/GYN appointments for:

  • First and second trimester: within seven calendar days of request
  • Third trimester: within three days of request
  • High-risk: within three calendar days of identification of high risk

UnitedHealthcare Community Plan periodically conducts surveys to check appointment availability and access standards. All care providers must participate in all activities related to these surveys.

Care Provider Directory

You are required to tell us, within five business days, if there are any changes to your ability to accept new patients. If a member, or potential member, contacts you, and you are no longer accepting new patients, report any Provider Directory inaccuracy. Ask the potential new patient to contact UnitedHealthcare Community Plan for additional assistance in finding a care provider.

Following CMS guidelines, we are required to contact all participating care providers annually and independent physicians every six months. We require you to confirm your information is accurate or provide us with applicable changes.

If we do not receive a response from you within 30 business days, we have an additional 15 business days to contact you. If these attempts are unsuccessful, we notify you that if you continue to be non-responsive we will remove you from our care provider directory after 10 business days.

If we receive notification the Provider Directory information is inaccurate, you may be subject to corrective action.

In addition to outreach for annual or bi-annual attestations, we are required to make outreach if we receive a report of incorrect provider information. We are required to confirm your information.

Additional Resources

Visit for the Provider Demographic Change Submission Form and further instructions.

Process of requesting approval from UnitedHealthcare Community Plan to cover costs. Prior authorization requests may include procedures, services, and/or medication.

Coverage may only be provided if the service or medication is deemed medically necessary, or meets specific requirements provided in the benefit plan.

You should take the following steps before providing medical services and/or medication to UnitedHealthcare Community Plan members:

  • Verify eligibility using Link at or by calling Provider Services. Not doing so may result in claim denial.
  • Check the member’s ID card each time they visit. Verify against photo identification if this is your office practice.
  • Get prior authorization from Link:
  1. To access the Prior Authorization app, go to, then click Link.
  2. Select the Prior Authorization and Notification app on Link.
  3. View notification requirements.

You may also find information on > Prior Authorization and Notification.

Identify and bill other insurance carriers when appropriate.

If you have questions, please call the UnitedHealthcare Connectivity Help Desk at 866-842-3278, option 3, 7 a.m. ‒ 9 p.m. Central Time, Monday through Friday.

Report all cases of suspected child abuse to Child Protective Services:


Report all cases of suspected dependent adult abuse to Adult Protective Services:

Specialists Include: Internal Medicine, Pediatrics, or Obstetrician/Gynecology

PCPs are an important partner in the delivery of care, and Hawaii Department of Human Services (DHS) members may seek services from any participating care provider. The Hawaii DHS program requires members be assigned to PCPs. We encourage members to develop a relationship with a PCP who can maintain all their medical records and provide overall medical management. These relationships help coordinate care and provide the member a “medical home.”

The PCP plays a vital role as a case manager in the UnitedHealthcare Community Plan system by improving health care delivery in four critical areas: access, coordination, continuity and prevention. As such, the PCP manages initial and basic care to members, makes recommendations for specialty and ancillary care, and coordinates all primary care services delivered to our members. The PCP must provide 24 hours a day, seven days a week coverage and backup coverage when they are not available.

Medical doctors (M.D.s), doctors of osteopathy (DOs), Advanced Practice Registered Nurses (APRN) and physician assistants (PAs) from any of the following practice areas can be PCPs:

  • General practice
  • Internal medicine
  • Family practice
  • Pediatrics
  • Obstetrics/gynecology
  • Geriatrics

Members may change their assigned PCP by contacting Member Services at any time during the month. Customer Service is available 7:45 a.m. – 4:30 p.m. HST, Monday through Friday.

We ask members who don’t select a PCP during enrollment to select one.

  • Medicare and Medicaid eligible members may choose an in-network or out-of-network PCP. Out-of- network PCPs will be identified on the member’s ID card as “Medicare PCP.”
  • Non-Medicare Medicaid eligible members must choose an in-network PCP. UnitedHealthcare Community Plan may auto-assign a PCP to complete the enrollment process.

You may print a monthly Primary Care Provider Panel Roster by visiting

Sign in to > select the UnitedHealthcare Online application on Link > select Reports from the Tools & Resources. From the Report Search page, select the Report Type (PCP Panel Roster) from the pull-down menu > complete additional fields as required > click on the available report you want to view.

The PCP Panel Roster provides a list of UnitedHealthcare Community Plan members currently assigned to a care provider.

Females have direct access (without a referral or authorization) to any OB/GYNs, midwives, physician assistants, or nurse practitioners for women’s health care services and any non-women’s health care issues discovered and treated in the course of receiving women’s health care services. This includes access to ancillary services ordered by women’s health care providers (lab, radiology, etc.) in the same way these services would be ordered by a PCP.

UnitedHealthcare Community Plan works with members and care providers to help ensure all members understand, support, and benefit from the primary care case management system. The coverage will include availability of 24 hours a day, seven days a week. During non-office hours, access by telephone to a live voice (i.e., an answering service, care provider on-call, hospital switchboard, PCP’s nurse triage) will immediately page an on-call medical professional so referrals can be made for non-emergency services. Recorded messages are not acceptable.

Consult with other appropriate health care professionals to develop individualized treatment plans for UnitedHealthcare Community Plan members with special health care needs.

  • Use lists supplied by the UnitedHealthcare Community Plan identifying members who appear to be due preventive health procedures or testing.
  • We recommend using these guidelines for preventive services:
  • Submit all accurately coded claims or encounters timely.
  • Provide all well baby/well-child services.
  • Coordinate each UnitedHealthcare Community Plan member’s overall course of care.
  • Accept UnitedHealthcare Community Plan members at your primary office location the same as any other coverage type (i.e., commercial plan)
  • Be available to members by telephone any time.
  • Tell members about appropriate use of emergency services.
  • Discuss available treatment options with members.

In addition to meeting the requirements for all care providers, PCPs must:

  • Offer office visits on a timely basis, according to the standards outlined in the Timeliness Standards for Appointment Scheduling section of this guide.
  • Conduct a baseline examination during the UnitedHealthcare Community Plan member’s first appointment.
  • Treat UnitedHealthcare Community Plan members’ general health care needs. Use nationally recognized clinical practice guidelines.
  • Refer services requiring prior authorization to the Prior Authorization Department, UnitedHealthcare Community Plan Clinical, or Pharmacy Department as appropriate.
  • Admit UnitedHealthcare Community Plan members to the hospital when necessary. Coordinate their medical care while they are hospitalized.
  • Respect members’ advance directives. Document in a prominent place in the medical record whether or not a member has an advance directive form.
  • Provide covered benefits consistently with professionally recognized standards of health care and in accordance with UnitedHealthcare Community Plan standards. Document procedures for monitoring members’ missed appointments as well as outreach attempts to reschedule missed appointments.
  • Transfer medical records upon request. Provide copies of medical records to members upon request at no charge.
  • Allow timely access to UnitedHealthcare Community Plan member medical records per contract requirements. Purposes include medical record keeping audits, HEDIS or other quality measure reporting, and quality of care investigations. Such access does not violate HIPAA.
  • Maintain a clean and structurally sound office that meets applicable Occupational Safety and Health Administration (OSHA) and Americans with Disabilities (ADA) standards.
  • Complying with the Hawaii DHS Access and Availability standards for scheduling emergency, urgent care and routine visits. Appointment Standards are covered in Chapter 2 of this manual.

Members may choose a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC) as their PCP.

  • Rural Health Clinic: The RHC program helps increase access to primary care services for Medicaid and Medicare members in rural communities. RHCs can be public, nonprofit or for-profit health care facilities. They must be located in rural, underserved areas.
  • Federally Qualified Health Center: An FQHC is a center or clinic that provides primary care and other services. These services include:
    • Preventive (wellness) health services from a care provider, physician assistant, nurse practitioner and/or social worker.
    • Mental health services.
    • Immunizations (shots).
    • Home nurse visits.

Take the following steps when providing services to UnitedHealthcare Community Plan members:

  • Verify eligibility using Link at or by calling Provider Services.
  • Verify member identity with photo identification, if this is your office practice.
  • Get prior authorization from UnitedHealthcare Community Plan, if required. Visit to locate and view the current prior authorization information and notification requirements.
  • Refer to UnitedHealthcare Community Plan participating specialists unless we authorize otherwise.
  • Identify and bill other insurance carriers when appropriate.
  • Bill all services provided to a UnitedHealthcare Community Plan member either electronically or on a CMS 1500 claim form. See Chapter 11 for more information on submitting forms.

In addition to applicable requirements for all care providers, specialists must:

  • Contact the PCP to coordinate the care/services.
  • Provide specialty care medical services to UnitedHealthcare Community Plan members recommended by their PCP or who self-refer.
  • Verify the eligibility of the member before providing covered specialty care services.
  • Provide only those covered specialty care services, unless otherwise authorized.
  • Provide the PCP copies of all medical data, reports and discharge summaries resulting from the specialist’s care.
  • Note all findings and recommendations in the member’s medical record. Share this information in writing with the PCP.
  • Maintain staff privileges at one UnitedHealthcare Community Plan participating hospital at a minimum.
  • Report infectious diseases, lead toxicity and other conditions as required by state and local laws.
  • Comply with the Hawaii DHS Access and Availability standards for scheduling routine visits. Appointment standards are covered in Chapter 2 of this manual.
  • Provide anytime coverage. PCPs and specialists serving in the PCP role must be available to members by phone 24 hours a day, seven days a week. Or they must have arrangements for phone coverage by another UnitedHealthcare Community Plan participating PCP or obstetrician. UnitedHealthcare Community Plan tracks and follows up on all instances of PCP or obstetrician unavailability.

Specialists may use medical residents in all specialty care settings under the supervision of fully credentialed UnitedHealthcare Community Plan specialty attending care providers.

UnitedHealthcare Community Plan also conducts periodic access surveys to monitor for after-hours access. PCPs and obstetricians serving in the PCP role must take part in all survey-related activities.

A specialist must be available at the hospital to which UnitedHealthcare’s PCPs admit its QUEST Integration members. A specialist with an ambulatory practice who does not have admission and treatment privileges must have written arrangements with another provider with admitting and treatment privileges with an acute care hospital within UnitedHealthcare’s network on the island of service. For the island of Hawai’i, this means that a care provider in East Hawai’i who does not have admission and treatment privileges shall have a written arrangement with another care provider with admitting and treatment privileges in East Hawai’i (same requirement applies to West Hawai’i).

Pregnant UnitedHealthcare Community Plan members should only receive care from UnitedHealthcare Community Plan participating providers.

Notify UnitedHealthcare Community Plan as soon as a member confirms pregnancy. This helps ensure appropriate follow-up and coordination by the UnitedHealthcare Hāpai Mālama coordinator.

If you have questions, call Hāpai Mālama. To begin patient outreach, fax the prenatal assessment form.

An obstetrician does not need approval from the member’s care provider for prenatal care, testing or obstetrical procedures. Obstetricians may give the pregnant member a written prescription at any UnitedHealthcare Community Plan participating radiology and imaging facility listed in the care provider directory.

Ancillary care providers include freestanding radiology, freestanding clinical labs, home health, hospice, dialysis, durable medical equipment, infusion care, therapy, ambulatory surgery centers, freestanding sleep centers and other non-care providers. PCPs and specialist care providers must use the UnitedHealthcare Community Plan ancillary network.

UnitedHealthcare Community Plan participating ancillary providers should maintain sufficient facilities, equipment, and personnel to provide timely access to medically necessary covered services.

Take the following steps when providing services to UnitedHealthcare Community Plan members:

  • Verify the member’s enrollment before rendering services. Go to Link at or contact Provider Services. Failure to verify member enrollment and assignment may result in claim denial.
  • Check the member’s ID card each time the member has services. Verify against photo ID if this is your office practice.
  • Get prior authorization from UnitedHealthcare Community Plan, if required. Visit > Prior Authorization and Notification.
  • Identify and bill other insurance carriers, when appropriate.