Claims, Appeals & Forms
Providers or members who wish to file a complaint or submit an appeal for a denied claim or service can find the necessary information in this section.
If you have any additional questions, feel free to contact us:
Hours: M–F, 8 am–6 pm
Phone: (801) 587-6480, option 1
Submit claims to the following address:
University of Utah Health Plans
Attention: Claims Department
PO Box 45180
Salt Lake City, UT 84145-0180
- Out-of-Network Liability and Balance Billing
- Enrollee Claim Submission
- Grace Periods and Claims Pending
- Retroactive Denials
- Recoupment of Overpayments
- Medical Necessity and Prior Authorization Timeframes and Enrollee Responsibilities
- Drug Exception Timeframes and Enrollee Responsibilities
- Explanation of Benefits
- Coordination of Benefits
Members have 180 days to appeal from Notice of Action Letter/EOB.
Please note: Effective January 1, 2016, the University of Utah Health Plans (UUHP) will require that providers obtain consent from a Healthy U or UHCP member, to appeal on their behalf, for denied claims or referrals, relating to clinical services. A Clinical appeal means services that were denied in a pre-service review, or services that were billed and require medical review, that
To File an Appeal
You, your legally authorized representative or your provider may file your appeal. If you need help filing your appeal, call us at (801) 587-6480, option 1. If you are deaf or hard of hearing, you can call Utah Relay Services at 711 or 1-800-346-4128.
If you or your provider believes your life or immediate health is in danger, you may ask for an expedited (quick) appeal by calling Customer Service at (801) 587-6480, option 1. If we agree the decision needs to be made quickly, we will make a decision in three calendar days.
Send the complete written appeal to this address:
Appeals Committee Chairperson
6053 Fashion Square Dr., Suite 110
Murray, UT 84107
If you want to file an appeal online, click here.
How long will it take for a decision to be made?
- Pre-Service Review: 30 calendar days
- Post-Service Review: 45 calendar days
If you disagree with the decision made by the University of Utah Health Plans, you can request a Voluntary External Appeal through an Independent Review Organization (IRO).
Voluntary External Appeal (IRO): For appeals related to issues relating to
Voluntary Expedited Appeal (IRO) is available for disagreement with the decision made in a pre-service review, and the member or the member representative believes that the service review is clinically urgent.To request an IRO, the request form is available at www.insurance.utah.gov
is fraud and abuse?
Fraud is when a person does something on purpose so that the person gets something he or she shouldn't. If a person tries to get health care from a doctor by using another person's U of U Health Plans card, that is one type of fraud. Another type of fraud is if a doctor bills U of U Health Plans on purpose for a service that wasn't done.
Abuse is when a person does something that costs U of U Health Plans extra money. If a U of U Health Plans member goes to the emergency room when it isn't really an emergency, that is one type of abuse. Another type of abuse is when a doctor does more services than the patient needs.
What can I do to stop fraud and abuse?
- Do not give your ID number to anyone except your doctor or provider.
- Do not ask your doctor or other providers for health care that you do not need.
- If you are offered free health care in exchange for your ID card number, call Healthy U.
- If someone says they know how to make U of U Health Plans pay for health care that we do not pay for, please call us.
- Do not let anyone use your ID card.
- Call us if a provider tries to make you pay for your care (except for your co-pay if you have one).
What can I do if I suspect fraud and abuse?
Fill out the Fraud and Abuse Reporting form above or call U of U Health Plan’s Compliance Officer at 1-888-271-5870, Option 1. You don't even have to tell us your name if you don't want to.
Care Coordination will be provided through our Care Management Department for the following:
- An individual that has been identified with a chronic health condition or health care need that may benefit from care manager support.
- An individual with health care needs that may want some help in making sure they care they receive is timely, appropriate and cost effective.
We encourage you to submit a pre-service request for medical review of the listed services.
The listed services require medical review for payment determination.
- Abortion services
- Bariatric procedures
- Cosmetic procedures
- Custom wheelchairs
- Durable medical equipment
- Home health care
- Implants, such as vagal nerve stimulators
- Outpatient therapies (ST)
- Pharmacy: injectables administered outside provider's office, hospital setting, or clinic
- Synagis immunization
- TMJ services
- Transplant services: lung heart, liver, kidney, bone marrow, cornea, and the like
We require notification for any inpatient admission. U of U Health Plans will be monitoring all inpatient hospital stays, including skilled nursing facilities and rehabilitation services.
Services deemed ‘medically necessary’ do not guarantee payment if coverage terminates, benefits change, benefit limits are exhausted or pre-existing conditions apply.
Utilization review means a review and confirmation program that determines medical necessity of any care service or treatment. In general, all covered benefits are based on medical necessity and utilization review is not limited to the above list.Individual & Family Plan - Utilization Review Guidelines