Health Choice Utah - 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

To appeal an adverse benefit determination (denied or limited authorization request) or a claim benefit denial, where the member could be liable for payment, please use the Appeal Form.
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 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)

Member Information

Member Name

Member ID Number

Member Phone Number

Member Street Address

Member 2nd Street Address

Member City

Member State

Member Zip Code

Submitter Information

Name of Person Submitting Appeal

Phone Number of Person Submitting Appeal

Provider Information

Name of Provider Involved

Provider NPI

Provider Correspondence Address

Provider Correspondence City

Provider Correspondence State

Provider Correspondence Zip Code

Provider Phone Number

Fax Number

Dispute Information

Request Type

Type of Service

Date(s) of service you are appealing

Claim Number(s) (if applicable)

Prior Authorization Number (if applicable)

Appeal Reason (Please Be Specific and Include Details)

Supporting Documents

Select file #1:

Select file #2:

Select file #3:

Select file #4:

If you would prefer to fax the information to the Appeals Team, please use fax number 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