Health Choice Utah - Complaint Form

Please use the Customer 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.
For Provider Disputes of claim billing denials or contract payment amounts, please use the Provider Dispute Form.
For any other concerns, complaints or grievances, please use this 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)

Member Information

Member Name

Member ID Number

Member Phone Number

Member Street Address

Member 2nd Street Address

Member City

Member State

Member Zip Code

Complaint Submitter Information

Are you the provider, the member, a vendor or a UUHP Customer Service Representative?

I am the:

Complaint Information

Request Type

Priority

Reporting Department

Date(s) of service related to complaint

Claim Number(s) if applicable

Referral number if applicable

The Reason(s) for the complaint (Please Be Specific and Include Details)

Provider Information

Name of Provider Involved

Provider NPI

Provider Street Address

Provider City

Provider State

Provider Zip Code

Provider Phone Number

Provider Fax Number

Provider Specialty

Email Confirmation

Confirmation Email

Complaint Documents

Select file #1:

Select file #2:

Select file #3:

Select file #4:

You can fax the information to the Complaint Team at the fax # 801-587-9985.

You may mail the information to:
Complaint Team
6056 Fashion Square Drive, Suite 3104
Murray, UT 84107