Provider Dispute Form

Please Note: Use this form if you are a Contracted Provider contacting us about a denied claim for billing issues such as timely filing, coding errors, or your claim payment amount .
Please use the Appeal Form to appeal an adverse benefit determination (denied or limited authorization request) or a claim benefit denial, where the member could be liable for payment
For Retail Pharmacy appeals (a medication dispensed to a member from a retail or specialty pharmacy), please use the Retail Pharmacy Appeal Form.
For Medical Pharmacy appeals (a medication administered to a member in a facility setting (provider or infusion center) or in the home dispensed from a home infusion pharmacy). Please use the Appeal Form.

Member Information

Provider Information

Case Information

Appeal Documents

If you would prefer to fax the information to the Appeals Team, please use fax # 801-587-9985.

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