Claims Processing

Claims Processing Cycle (UHA Providers)

Claims Processing Cycle via EDI provides a quicker turnaround time on provider claims since it will eliminate the need for UHA to manually process the majority of the claims. However, the length of time required to process a claim depends on many variables in addition to the medium on which they are received. Claims submitted before 7:00 PM Hawaii Standard Time will normally be processed that evening.

Registration and Approval by UHA

UHA requires prior approval of any EMC and EDI submission arrangements from any source. There are two parts to the approval process. Part One concerns the technical details of the data processing arrangement to be used. Part Two relates to the specific provider whose transactions are submitted via electronic data interchange. UHA must review and approve each provider’s request to participate, and each provider is required to sign an Electronic Trading Partner Agreement. UHA reserves the right to revoke approval for a provider, group of providers, or organization participating in electronic data interchange with UHA. On-Site Inspection In order to ensure that the established UHA requirements are being met, providers must agree to allow periodic audits by UHA and its authorized representatives after implementation of this arrangement to verify that the necessary records are being retained in accordance with the Electronic Trading Partner Agreement.

For all UHA claims, the provider should verify his/her patient’s data file with current identification information obtained from each encounter, since claims with invalid or incorrectly formatted membership numbers will not be accepted for EMC processing. Providers should establish a procedure to contact those patients to obtain information so their data files can be updated.

To learn more about EDI and become a certified  EDI Professional please visit our course schedule page.

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