CurrentUnitedHealthcarePolicy N/A

Hawaii authorization request for air transportation, lodging and meals

A fillable authorization request form and instructions for UnitedHealthcare members in Hawaii requesting coverage for air transportation, lodging, meals, attendant and related travel needs for out-of-area medical care. Affects members, PCPs, and referring/rendering providers involved in arranging travel.

Policy Summary

PayerUnitedHealthcare

PolicyHawaii authorization request for air transportation, lodging and meals

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization request form with clinical attachments by fax and indicate urgency if applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Travel, lodging, mealsTypes of supports captured on form

Member, PCP, Referring, Rendering, AppointmentDistinct info sections

Urgent flagUrgency indicator

FaxSubmission method

Information Required to Evaluate Authorization

Policy Summary

PayerUnitedHealthcare

PolicyHawaii authorization request for air transportation, lodging and meals

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization request form with clinical attachments by fax and indicate urgency if applicable.

SourceLink

On This Page

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ALL of the following

Member and trip details
- Departure city/airport (and arrival city/airport)
- Departure date and return date
- Type of ticket (One-way or Round-trip)
- Ground transportation requirement (Home island, Neighbor island, Mainland, Not required)
Clinical justification for out-of-state travel
- Attach clinical information to support any request to travel out of state
- Medical reason for treatment including diagnosis and specific reason for request (e.g., no specialist on island, procedure cannot be done on island)
- Medical reason for stay longer than 1 day (if applicable)
Appointment and provider information
- Rendering physician name, phone and specialty
- Facility name and physical street address (island or state)
- Appointment start date and check-in time
- Appointment end date and end time (if applicable)
Support needs and accommodations
- Attendant required (Yes/No) and medical reason for attendant; name of adult attendant as listed on valid photo ID
- Wheelchair details: Member provides wheelchair? (Yes/No); type of wheelchair; able to transfer in/out of wheelchair? (Yes/No) — do not use lodging/transport fields to request airport wheelchair assistance
- Oxygen required (Yes/No). If Yes, specify delivery method (nasal, mask), O2 and flow rate
- Meals required (Yes/No) and Lodging required (Yes/No)
Documentation and submission note
- Attach clinical documentation and all supporting information to the completed authorization request form for evaluation

If multiple appointments or additional appointment details exist, provide each appointment's start and end dates/times and facility information

Submission and Required Documentation

Prior Authorization

Submission and required documentation (fax and attachments)

Submit the completed Hawaii authorization request form with all required clinical attachments by fax to 800-267-8328. Indicate 'Urgent' on the form if the request is time-sensitive and include travel details (departure/arrival city and dates), medical justification for out-of-state travel, attendant information when applicable, and any supporting documentation for lodging, meals, oxygen, or wheelchair needs.

Fax submissions only: send to 800-267-8328 and mark 'Urgent' if applicable.
Attach clinical information to support any request to travel out of state (medical reason for stay longer than 1 day and treatment details).
Provide travel details: departure/arrival city and airport, departure and return dates.
If attendant required, include medical reason and attendant name as listed on valid photo ID.
Document needs for ground transportation, wheelchair assistance, meals, lodging, and oxygen, including type/flow rate for oxygen when applicable.

Form Field Definitions and Clarifications

inv-03: Attendant required

Attendant requiredYes/No — indicate whether an adult attendant is required to accompany the member.

Medical reason for attendantProvide the medical reason that justifies the attendant’s presence.

Attendant identityName of adult attendant (as listed on valid photo ID); include gender and date of birth as provided on the form.

Ticket type relevanceIndicate type of ticket (One-way or Round-trip) to reflect attendant travel needs.

Attachments requiredAttach clinical information to support the need for an attendant when requesting out-of-state travel.

inv-04: Wheelchair assistance

Wheelchair assistance noteDo not use the lodging/transport fields to request airport wheelchair (W/C) assistance — those fields are not for airport W/C needs.

Member wheelchair statusIndicate whether member provides their own wheelchair (Member provides W/C? Yes/No) and specify what type.

Transfer abilityIndicate whether member is able to transfer in/out of wheelchair (Yes/No).

Ground transportation optionsSpecify ground transportation required: Home island, Neighbor island, Mainland, or Not required — this is separate from airport W/C assistance.

Supporting documentationAttach clinical information to support any request to travel out of state, including needs for wheelchair or other transport assistance.