Claims & Appeals

• 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
• Pharmacy Prior Authorization and Medical Necessity Policy Timeframes and Enrollee Responsibilities
• Explanation of Benefits
• Coordination of Benefits

• Appeals Form
• Consent Form
• Complaint Form
• Fraud & Abuse Form
• Referral Form

Medicare Advantage: Contracted Provider Appeals must be received within 120 days from the date on Notice of Action or EOB. Non-contracted Provider Appeals must be received within 60 days from the date on Notice of Action or EOB. Non-contracted Provider disputes must be received within 120 days from the date on Notice of Action or EOB. Members or their authorized representatives may file an appeal up to 60 calendar days after the date of a denial.

Medicaid: Appeals must be received within 90 days from the date on Notice of Action or EOB.

Neurobehavioral HOME: Appeals must be received within 30 days from the date on the Notice of Action or EOB.

UHCP, U of U Health Plans Group, and Individual Plans Appeals: Members have 180 days to appeal from Notice of Action Letter/EOB.

UNI & Miners: Please contact appeal coordinators at 801-587-6480 or 888-271-5870.

Please note:Effective January 1, 2016, the University of Utah Health Plans ( U of U Health Plans) 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 were denied.

To File an Appeal, make a Complaint, or Ask for Reconsideration of a Decision Related to an Authorization, Service, Benefit, or Plan Policy

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. If you are deaf or hard of hearing, you can call Utah Relay Services at 711 or 1-800-346-4128. You also have the right to an independent, external review of final internal UM determinations.

Appeals Form

Español

Si necesita esta carta en Español, por favor llamenos al 801-587-6480 o 1-888-271-5870. Si habla español, puede llamar a Spanish Relay Utah al 1-888-346-3162. These are free public telephone relay services or TTY/TDD. Estos son servicios gratuitos de retransmisión telefónica pública o TTY / TDD.

Submission Information:
Send the complete written appeal to this address:
Appeals Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107
Or you can Fax to:
801-281-6121

Response Time

How long will it take for a decision to be made?

Medicare Advantage: 60 calendar days. Commercial: 45 calendar days. Medicaid: 30 calendar days.

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. If we agree the decision needs to be made quickly, we will make a decision in 3 calendar days for UUHP/Group and Individual Plans or three working days for Healthy U.

For Routine or Expedited Appeals: Sometimes we may need more information. If so, we may take an additional 14 calendar days to make our decision. If we need to take extra time, we will send you a letter. If you have U of U Health Plans Group or Individual Plans, we will call you to explain why we need more time. We need your permission to take the extra time for the appeal review.

What 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. You don't even have to tell us your name if you don't want to.
Fraud & Abuse Reporting Form

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
• Prosthetics
• 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.
Group Plans - Utilization Review Guidelines