Forms - Health Choice Utah

Request Type:

Submitter:

Member Name:

Member ID Number:

Member Street Address:

Member 2nd Street Address:

Member City:

Member State:

Member Zip Code:

Member Phone Number:

Name of Provider Involved:

Provider Correspondence Address:

Provider Correspondence City:

Provider Correspondence State:

Provider Correspondence Zip Code:

Provider Phone Number:

Fax Number:

Provider NPI:

Type of Service:

Name of Person Submitting Appeal:

Phone Number of Person Submitting Appeal:

Date(s) of service you are appealing:

Appeal Type:

Claim Number(s) (if applicable):

Prior Authorization Number (if applicable):

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

Select file #1:

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
6056 S. Fashion Square Drive, Suite 3940
Murray, UT 84107