Forms - Health Choice Utah

Request Type:

Please provide the identification number of the main request or other information to associate the requests. *

Requested By:

Request Urgency:

Please Note: Expedited requests require immediate action. Expedited requests should be reserved for situations where application of the time frame for making routine care determinations could seriously jeopardize the life, health or safety of the member. It includes situations where lack of the requested treatment would subject the member to severe adverse health consequences.

If expedited, please acknowledge:

Is this life threatening?
Would this subject the member to severe health consequences without the requested care?
Does not meet these criteria.

Please Provide Expedited Details: *

If you called us to file an appeal, a Customer Advocate can file a written appeal on your behalf, if you give verbal consent. I give my verbal consent for this request to be considered a written appeal. I agree this information is correct and complete to the best of my knowledge.

Yes
No

CRM number (for UUHP Representatives only):

*Please complete the Member Consent form and submit with your appeal

Member Information

Member Name:

Member ID Number:

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Member Street Address:

Member 2nd Street Address:

Member City:

Member State:

Member Zip Code:

Member Phone Number:

Member Plan:

Provider Information

Name of Provider Involved:

Provider Correspondence Address:

Provider Correspondence City:

Provider Correspondence State:

Provider Correspondence Zip Code:

Provider Phone Number:

Provider Fax Number

Provider NPI:

Appeal Information

Request Reason:

Name of Medication

Quantity

Day Supply

Diagnosis Code:

Prior Authorization Number (if applicable):

Name of Person Submitting Appeal:

Phone Number of Person Submitting Appeal:

Have the services been provided?

If your appeal is for a denied or reduced service (e.g., benefits are being reduced for home health care), do you have an urgent health need or is your life in danger? Would you like to ask for a quick review?

No
Yes (If we agree you need a quick review, we will make a decision on your appeal within 72 hours.)

Please Note: Urgent requests require immediate action. Urgent requests should be reserved for situations where application of the time frame for making routine care determinations could seriously jeopardize the life, health or safety of the member. It includes situations where lack of requested treatment would subject the member to severe adverse health consequences.

If urgent, please acknowledge:

Is this life threatening? Yes No

Would this subject the member to severe health consequences without the requested care? Yes No

Does not meet these criteria. Yes No

Please Provide Urgent Details: *

Appeal Reason (Please Be Specific and Include Details):

If your appeal is about a service you get that is ending or being reduced do you want to get the service during the appeal review? You will need to file your appeal within 10 calendar days of the Notice of Action or the intended date of Healthy U planned action. You can choose to keep getting service(s) during your appeal but you might have to pay for them if we do not decide in your favor.

Yes
No

Do you want to appear in person to present your appeal? If yes, we'll send you a notice of the date, time, and location to present your appeal.

Yes
No

You have the right to submit comments, documents or information relevant to the appeal. Do you have more information you would like to send for the appeal? You can attach records below.

Yes
No

Appeal Documents

Select file #1: clear Select file #2: clear Select file #3: clear Select file #4: clear Select file #5: clear

If you would prefer to fax the information to the Retail Pharmacy Appeals Team, please use fax # 801-646-4746.

If you would prefer to mail the information to the Retail Pharmacy Appeals Team, please use:
Retail Pharmacy Appeals Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107