Out-of-State (Mainland) Medical Service Reimbursement and Coordination
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Policy governing prior authorization, reimbursement, and coordination for medically necessary services provided on the U.S. mainland for University Health Alliance members when those services are not available in Hawaii; applies to members of UHA and referring providers managing mainland referrals.
No material clinical or coverage changes in this revision.
Out-of-State Coverage Criteria
Out-of-state service reimbursement criteria
Covered when ALL of the following are met:
ALL of the following
- Prior authorization obtained
Prior authorization required for all out-of-state medically necessary services not available in Hawaii; two weeks' advance notice requested for routine requests (expedited review for time-sensitive situations).
- Service is medically necessary and not available in Hawaii
- Notification to UHA Health Care Services (RN Care Specialist, Health Care Services Liaison, Medical Director, or Chief Medical Officer) has occurred
Providers must call UHA Health Care Services (808-532-4006 or neighbor islands 1-800-458-4600) and discuss the referral; UHA may discuss financial implications with the member.
ALL of the following
- Patient's diagnosis/condition and pertinent comorbidities (including notes and test results)
- Clinical nuances favoring techniques not available in Hawaii
- Detailed description of requested service and mainland provider/facility contact information
- Specific explanation why related services available in Hawaii are insufficient
- Name and notes from a Hawaii specialty physician who concurs that out-of-state services are necessary
- Supporting research when based on new, experimental, or investigational treatments
CMO/Medical Director will query Hawaii-based specialists as needed; unclear or disputed determinations may be referred to an Independent Review Organization (IRO).
Coding and Reimbursement Rules
| IMPLANT_REIMB | When implant is used, UHA requires invoice and will reimburse invoice +10%. |
Provider Responsibilities and Prior Authorization
Prior authorization and timing requirements
Prior authorization is required for all out-of-state medical services that are medically necessary and not available in Hawaii. Providers should request prior authorization at least two weeks in advance to verify medical necessity and arrange payment; genuine emergencies will be expedited (reviewed within 72 hours) and retrospective prior authorization for non‑emergent care is discouraged and may result in significant patient expense.
- Two weeks' advance notice is required for prior authorization to verify payment criteria and make payment arrangements with the mainland provider.
- Genuine emergencies are time‑sensitive and will be reviewed and acted upon promptly (target 72 hours).
- Retrospective prior authorizations in non‑emergent situations may not be approved and can result in significant expenses for the patient.
Notify UHA and coordinate referral with RN Care Specialist
Notify UHA Health Care Services of any potential mainland referral and discuss the case with an RN Care Specialist, Health Care Services Liaison, Medical Director, or the Chief Medical Officer; UHA may also discuss financial implications with the member.
- Call UHA Health Care Services at 808-532-4006 or neighbor islands 1-800-458-4600 to notify and discuss referrals.
- Coordinate the referral conversation with an RN Care Specialist, Health Care Services Liaison, Medical Director, or Chief Medical Officer.
Submit required documentation with prior authorization
Provide complete, legible documentation with the prior authorization submission; failure to supply required information may delay review or result in denial.
- Include patient's condition/diagnosis and pertinent comorbidities, and pertinent notes and test results.
- Describe clinical nuances, detailed description of requested service, mainland provider/facility name and contact information.
- Explain why related services available in Hawaii are not sufficient and include concurrence notes from a Hawaii specialty physician.
- Submit any current research supporting medical necessity for new or experimental treatments.
Prefer UnitedHealthcare Choice Plus Network providers; consult RN Care Specialist
Use UHA's contracted UnitedHealthcare Choice Plus Network providers on the mainland when possible and ask RN Care Specialists to help identify participating providers; participation may reduce member costs but is not guaranteed for all component providers.
- Referring to a UnitedHealthcare Choice Plus Network provider may produce substantial savings for members but may still result in higher copayments versus UHA eligible charges.
- There is no guarantee a participating UnitedHealthcare Choice Plus provider exists in every area, and not all providers involved in a service (e.g., pathologists, anesthesiologists) will necessarily participate.
Coordinate transplants and specialized care through UHA prior authorization
For transplants (other than kidney and liver), congenital heart disease, and certain cancers, contact UHA Health Care Services prior to arranging care — services at preferred facilities require prior authorization and must be coordinated by UHA.
- UHA has special agreements with preferred facilities for specified transplants and specialized services.
- Services at these preferred centers are subject to UHA prior authorization requirements and coordination by UHA.
Definitions and Timing
Transplant Candidate and Center Criteria
Preferred transplant centers and coordination
Criteria for use of preferred transplant centers and required coordination:
ALL of the following
- Service is to be provided at a UHA-designated preferred facility (transplants other than kidney and liver, congenital heart disease, certain cancers)
- Prior authorization obtained and care coordinated through UHA Health Care Services
Services at preferred centers require prior authorization and must be coordinated by UHA.
- Referring provider contacts UHA prior to making arrangements
Contact UHA Health Care Services to initiate coordination so UHA can apply special agreements and make payment arrangements.
Evaluation and Authorization Requirements
Evaluation requirements for transplant referrals
For transplant evaluations, submit standard prior authorization documentation and demonstrate that the requested services are not available in Hawaii; UHA may request concurrence from a Hawaii specialty physician as part of the evaluation.
- Provide diagnosis, pertinent notes/tests, description of requested service, and rationale why Hawaii options are insufficient.
- Concurrence from a Hawaii specialty physician may be requested to support the out-of-state evaluation.
Facility and Center Requirements
Coordinate centers through UHA prior authorization and agreements
All facilities for out-of-state care must be coordinated through UHA prior authorization and are subject to UHA agreements and administrative review; services at preferred centers require UHA coordination and prior authorization.
- Facilities and services must be coordinated by UHA and meet prior authorization requirements.
- UHA reserves the right to perform retrospective review to validate services met payment criteria.
Post-Transplant Coordination and Coverage
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