Forms - Health Choice Utah

Please Note: Use this 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 this form.
For Provider Disputes of claim billing denials or contract payment amounts, please use the Provider Dispute Form found here.
For other complaints, please use the Customer Complaint Form.

If you need help filling out this form, call us at 877-358-8797. (Si necesita ayuda para llenar o completar este formulario, llamenos al 877-358-8797)

Request Type:

Submitter:

Member Information

Member Name:

Member ID Number:

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:

Fax Number:

Provider NPI:

Appeal Documents

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
6053 Fashion Square Dr., Suite 110
Murray, UT 84107