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Printable PDF Forms
Reference & Training | Healthy U CHIP Provider Manual | Print PDF Form |
Reference & Training | Identifying Our Members Flyer | Print PDF Form |
Credentialing | Facility Credentialing Infographic | Print PDF Form |
Credentialing | Provider Credentialing Infographic | Print PDF Form |
Credentialing | Organizational Provider Credentialing Application | Print PDF Form |
Credentialing | Credentialing Policy | Print PDF Form |
Credentialing | Denial, Termination and Fair Hearing Plan Policy | Print PDF Form |
Preservice | Authorization Request for Preservice (Prior Authorization) | Print PDF Form |
Preservice | Authorization Request for Inpatient, ICF, SNF, Acute Rehab and LTAC | Print PDF Form |
Preservice | Authorization Request for Behavioral Health/Substance Treatment | Print PDF Form |
Claims & Appeals | Request to Reopen an Organizational Determination for Medical Review | Print PDF Form |
Preservice | Peer to Peer Review Request Form (PDF) | Print PDF Form |
Preservice | Peer to Peer Review Request Form - Pharmacy (PDF) | Print PDF Form |
Claims & Appeals | Consent Form | Print PDF Form |
Claims & Appeals | Healthy U Sterilization Hysterectomy Form Cover Sheet | Print PDF Form |
Claims & Appeals | Medical Claim Form | Print PDF Form |
Member Support | Authorization for Release of Information | Print PDF Form |
Reference & Training | Healthy U Behavioral Preferred Practice Guidelines | Print PDF Form |
Claims & Appeals | Open Negotiation Form (No Surprises Act) | Print PDF Form |
Preservice | Upcoming Changes to Codes Requiring Prior Authorization | Print PDF Form |
Claims & Appeals | EDI Form for 835, 837 (Trading Partner Setup) & EFT Enrollment (Electronic Funds Transfer) | Print PDF Form |
References & Training
Clinical Practice Guidelines
Position Statement: University of Utah Health Plans adopts guidelines to help practitioners and members make decisions about appropriate care for specific medical and behavioral health conditions. The following guidelines are based on scientific evidence, and where evidence is lacking, on a consensus of panel experts, and are supported by University of Utah Health Plans. Guidelines are not a substitute for professional medical advice.
Behavioral Health Guidelines
Category | Resource |
---|---|
Depression | APA Clinical Practice Guideline for the Treatment of Depression |
Perinatal Depression | Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum |
Attention Deficit Hyperactivity Disorder (ADHD)- Pediatrics | Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents |
Attention Deficit Hyperactivity Disorder (ADHD)- Adults | European Consensus Statement for the Diagnosis, Management, and Treatment of Adult ADHD |
Substance Use Disorder | Implementing Care for Alcohol and Other Drug Use in Medical Settings |
Substance Use Disorder – Level of Care Criteria | American Society of Addition Medicine (ASAM) Level of Care Placement Criteria |
Opioid Prescribing | CDC Guideline for Prescribing Opioids for Chronic Pain |
Medical Guidelines
Preventive Health Guidelines - Child
Category | Resource |
---|---|
Immunizations- Pediatric | Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, United States |
Well Child Visits - Pediatric | American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care |
Well Child Visits - Pediatric | Periodicity Schedule |
Preventive Health Guidelines - Adult
Shared Decision Making
University of Utah Health Plans is excited to promote the use of shared decision making tools for providers to engage University of Utah Health Plan members. Beyond pamphlets or health reference information materials - Shared decision-making tools are built to guide a patient through a treatment decision point in their health care together with collaboration, guidance, and the expertise of their clinicians.
“Shared decision making is a key component of patient centered health care. It is a process in which clinicians and patients work together to make decisions and select tests, treatments and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values.”
Shared Decision Making Fact Sheet, 2013, National Learning Consortium.
The development of shared decision-making tools (SDM’s) has increased in the last decade. University of Utah Health, with a $5 Million Grant from the Patient-Centered Outcomes Research Institute and the American Heart Association, is creating a center to develop and test SDM’s for Atrial Fibrillation. The Mayo Clinic will be a collaborative partner for conducting the research.
“If people don’t feel engaged in the decision-making process they are less likely to see the benefits of treatments. Instead they may see them as a hassle and not fill their prescriptions or take the medications"
-
Angie Fagerlin, Ph.D.
, chair of Population Health Sciences at University of Utah Health
Shared Decision Making
The Mayo Clinic's Statin Decision Tool was designed to assist the patient and their doctor discuss methods for potentially reducing their risk for heart attacks.
Provider Connection Newsletters
If you haven’t already, please subscribe—via the link at the bottom of the page—to receive notice when new editions are available. Encourage others in your office to subscribe to receive notice, as well. From clinical to administrative, there’s something for everyone.
2025 | May 2025 Newsletter | Download Newsletter (PDF) |
2025 | February 2025 Newsletter | Download Newsletter (PDF) |
2024 | November 2024 Newsletter | Download Newsletter (PDF) |
2024 | August 2024 Newsletter | Download Newsletter (PDF) |
2024 | May 2024 Newsletter | Download Newsletter (PDF) |
2024 | March 2024 Prior Authorization Special Edition Newsletter | Download Newsletter (PDF) |
2024 | February 2024 Newsletter | Download Newsletter (PDF) |
2023 | May 2023 Newsletter | Download Newsletter (PDF) |
2023 | August 2023 Newsletter | Download Newsletter (PDF) |
2023 | November 2023 Newsletter | Download Newsletter (PDF) |
2023 | February 2023 Newsletter – Special PRISM Edition | Download Newsletter (PDF) |
2023 | February 2023 Newsletter | Download Newsletter (PDF) |
2022 | November 2022 Newsletter | Download Newsletter (PDF) |
2022 | August 2022 Newsletter | Download Newsletter (PDF) |
2022 | May 2022 Newsletter | Download Newsletter (PDF) |
2022 | Feb 2022 Newsletter | Download Newsletter (PDF) |
2021 | Aug 2021 Newsletter | Download Newsletter (PDF) |
2021 | May 2021 Newsletter | Download Newsletter (PDF) |
2021 | February 2021 Newsletter | Download Newsletter (PDF) |
2020 | November 2020 Newsletter | Download Newsletter (PDF) |
2020 | August 2020 Newsletter | Download Newsletter (PDF) |
2020 | May 2020 Newsletter | Download Newsletter (PDF) |
2020 | February 2020 Newsletter | Download Newsletter (PDF) |
2019 | November 2019 Newsletter | Download Newsletter (PDF) |
2019 | August 2019 Newsletter | Download Newsletter (PDF) |
2019 | May 2019 Newsletter | Download Newsletter (PDF) |
2019 | February 2019 Newsletter | Download Newsletter (PDF) |
2018 | End-of-Year 2018 Newsletter | Download Newsletter (PDF) |
2018 | Fall 2018 Newsletter | Download Newsletter (PDF) |
2018 | Summer 2018 Newsletter | Download Newsletter (PDF) |
2018 | Spring 2018 Newsletter | Download Newsletter (PDF) |
2017 | November 2017 Newsletter | Download Newsletter (PDF) |
2017 | October 2017 Newsletter | Download Newsletter (PDF) |
2017 | June 2017 Newsletter | Download Newsletter (PDF) |
2017 | February 2017 Newsletter | Download Newsletter (PDF) |
2017 | January 2017 Newsletter | Download Newsletter (PDF) |
2016 | Spring 2016 Newsletter | Download Newsletter (PDF) |
2014 | Summer 2014 Newsletter | Download Newsletter (PDF) |