We cannot always agree on every decision. In those situations, you can request a review, appeal a decision or file a complaint.
Your healthcare benefits are personal and we understand protecting your rights.
|Need to File a Claim?||If you need to submit a claim to University of Utah Health Plans directly, submit claims to:
|University of Utah Health Plans Policies||
|Appeals Process and Rights||
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
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 833-981-0213.
Please note:Effective January 1, 2016, the University of Utah Health Plans (
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 833-981-0213. 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.
Si necesita esta carta en Español, por favor llamenos al 833-981-0213. 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.
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 833-981-0213. 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 UUHP 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.
Surprise Billing or Balance Billing
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. Learn more about surprise billing.
|Fraud & Abuse||
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?
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 833-981-0213. You don't even have to tell us your name if you don't want to.
|Utilization Review Guidelines||
Care Coordination will be provided through our Care Management Department for the following:
We encourage you to submit a pre-service request for medical review of the listed services.
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.