Claims, Appeals & Forms

University of Utah Health Plans

Frequently Used Forms

• Appeals Form
• Retail Pharmacy Appeals Form
• Consent Form
• Complaint Form
• Fraud & Abuse Form

Surveys

• Commercial Utilization Management Member Survey
• Commercial Utilization Management Provider Survey

Healthy U Medicaid

Frequently Used Forms

• Appeals Form
• Retail Pharmacy Appeals Form
• Consent Form
• Complaint Form
• Fraud & Abuse Form
• Referral Form
• Neurobehavioral HOME Appeal Form

Surveys

• Healthy U Utilization Management  Member  Survey
• Healthy U Utilization Management  Provider  Survey

Appeal Rights

Advantage U (Medicare PPO) plans: Appeals must be received within 60 calendar days from the date of initial determination notification.

Healthy U Medicaid: Appeals must be received within 60 days from the date on Notice of Action or EOB.

Neurobehavioral HOME: Appeals must be received within 60 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 801-213-4008 or 833-981-0213.

Please note: Effective January 1, 2016, the University of Utah 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 denied.   

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 801-213-4008. If you are deaf or hard of hearing, you can call Utah Relay Services at 711 or 1-800-346-4128.

Appeal Form

Retail Pharmacy Appeals Form

Healthy U Medicaid Appeal Form

Healthy U Retail Pharmacy Appeals Form

Español

Si necesita esta carta en Español, por favor llamenos al 801-213-4008 o 1-833-981-0213 opcion 1.  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
6056 Fashion Square Dr., Suite 3104
Murray, UT 84107

Or you can fax to 801-587-9985

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 801-213-4008. If we agree the decision needs to be made quickly, we will make a decision in three calendar days for U of U Health Plans/Group and Individual Plans or 72 hours for Healthy U Medicaid.

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.

The University of Utah Health Plans is committed to detecting, preventing, correcting, and reporting suspected FWA behaviors, and will comply with all applicable state and federal laws, rules and regulations.

What is FWA?

Fraud is the intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to them or some other person.

Examples of Fraud may include:

• Knowingly ordering medically unnecessary patient items or services
• Knowingly billing and/or documenting in the patient’s medical records, services of higher complexity than what were actually provided

Waste is the overutilization of services or other practices that directly or indirectly result in unnecessary costs to a state or federal healthcare program. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources.

Examples of Waste may include:

• Conducting excessive office visits
• Ordering excessive laboratory or diagnostic tests

Abuse includes practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the healthcare program. These practices include reimbursement for services that are not medically necessary, that fail to meet professionally recognized standards for healthcare, and recipient practices that result in unnecessary cost to the healthcare program (42 CFR 455.2).

Examples of Abuse may include:

• Billing for unnecessary medical services
• Charging excessively for services or supplies

What Are My Responsibilities?

You are a vital part of the effort to prevent, detect, correct, and report suspected FWA.

Comply with all applicable statutory and regulatory requirements, laws, regulations, policies, and guidelines.

• Bill for services according to what was provided and follow proper coding guidelines
• Ensure your data and billing is accurate and timely
• Monitor and maintain accurate and complete medical records to ensure the documentation support the services you rendered
• Perform regular internal audits
• Make sure you are up-to-date with the laws, regulations, guidelines, and policies
• Be on the lookout for suspicious activity

Follow your organization’s Code of Conduct that describes your commitment to standards of conduct and rules of ethical behavior.

• If FWA is detected, promptly correct it; develop an action plan to fix the underlying problem(s) that resulted in the FWA violation, to prevent future occurrences
• Establish effective lines of communication with your colleagues and staff members

Promptly report any violation of laws of which you may be aware.

How To Report Suspected FWA?

All entities including contracted and non-contracted providers and staff, have a duty to report suspected FWA behaviors.

• Suspected FWA can be reported anonymously
• When reporting suspected FWA, even if choosing to remain anonymous, always provide specific details and ensure all essential questions (who, what, where, why, and how) are addressed in the reporting form. Report suspected FWA by one of the following methods
  • U of U Health Plans FWA Email: HealthPlansReportFraud@utah.edu
  • Online Form: Fraud & Abuse Reporting Form
  • EthicsPoint Hotline: 888-206-6025 – Anonymity and interpretation services are available
  • EthicsPoint: secure.ethicspoint.com

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.

We encourage you to submit a pre-service request for medical review of the listed services.

• 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, hosptial 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-exisiting 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.

University of Utah Health Plans - Utilization Review Guidelines

The No Surprises Act becomes effective January 1, 2022. This law represents a significant change in the way non-contracted and out-of-network providers can bill and be reimbursed by University of Utah Health Plans (U of U Health Plans). The Act prohibits balance billing of members by non-contracted and out-of-network providers for the following:

• Out-of-network emergency items and services
• Covered medical items and services (nonemergency) performed by an out-of-network provider at an in-network HealthPartners contracted facility
• Out-of-network air ambulance (rotary and fixed wing) items and services 

For each item or service identified with remark codes N859 and N860, the payment amount listed for each item or service is the Qualifying Payment Amount (QPA). The QPA applies for purposes of the recognized amount, or, in the case of air ambulance services, for calculating the applicable member cost sharing. Each QPA has been determined in compliance with the requirements of the No Surprises Act. Noncontracted providers may initiate a 30-day open negotiation period for purposes of determining the amount of total payment by contacting U of U Health Plans Appeals Team to initiate open negotiation. You may initiate the No Surprises Act independent dispute resolution process within 4 days after the end of the 30-day open negotiation period if a determination of the total payment, including cost-sharing, is not reached. 

To begin the Open Negotiation process, please submit the Open Negotiation Form to U of U Health Plans via:

• Email at: UUHP_Appeal_Compliance_Team@hsc.utah.edu
• Fax at: 801-587-9985
• Mail at: 
  • University of Utah Health Plans
    Attention: Appeals Team
    6056 Fashion Square Drive, Suite 3104
    Murray, UT 84107

The parties must undertake an open negotiation period prior to initiating the Federal Independent Dispute Resolution (IDR) process and meet all timeliness requirements. Notification of IDR initiation should be submitted using the Notice of IDR Initiation (OMB Control No. 1210-0169 to the email, fax, or mailing address above.