Organizational/Provider Contracting Application

University of Utah Health Plans Provider Networks

Indicate the networks with which you are interested in participating:

Healthy U – A Utah Medicaid Accountable Care Organization (ACO) network available to eligible Medicaid members for physical health coverage throughout the entire state of Utah. Healthy U CHIP – A statewide provider network, effective July 1, 2024, to support the Children’s Health Insurance Program, a state-sponsored physical and behavioral health insurance plan for children who do not have other insurance. Healthy U Behavioral – A Medicaid mental health and substance use network available to eligible Davis, Salt Lake, Summit, Utah, and Weber County residents. Healthy Premier – A provider network for employer groups in Utah and Southeastern Idaho. It is also available on the Utah Individual Marketplace Exchange. Healthy Preferred – A provider network for employer groups along the Wasatch Front from Cache to Utah counties and Summit to Tooele counties. U Health Plus – A narrow commercial provider network offered within Salt Lake County only.

Note: This application does not apply to the Huntsman Mental Health Behavioral Health Network (HMHI BHN). If you are interested in becoming a participating provider with HMHI BHN, then please contact: Jessie.Konate@hsc.utah.edu or call 801-646-7363.

Completion of this application does not guarantee a contract or participation with University of Utah Health Plans.

Completely describe your services or scope of practice in the space below and/or attach any relevant marketing materials describing your services.

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Marketing Materials

Sender Information

This information is for the person we should contact if there are any issues with the application.

Sender Contact Name

Sender Contact Email

Sender Contact Phone

Organization Information

Legal Name of Practice/Parent Company

W-9 Form

DBA Name of Practice

Practice or Group's Specialty

Organization URL

Practice Medicaid Prism ID #

Practice TIN

Practice NPI

Practice licensed to operate in state?

Yes

Is Practice Accredited?

Yes

Does Practice submit claims electronically?

Yes

Is group hospital based only?

Yes

Contracting Contact Information

Street Address

Address Line 2

City

State

Zip/Postal Code

Contact Name

Phone

Fax

Credentialing Contact Information

Click here if Credentialing Contact Information is the same as Contracting Contact Information

Street Address

Address Line 2

City

State

Zip/Postal Code

Contact Name

Phone

Fax

Location(s)

Check here if your organization/practice does not have individual providers.

Provider(s)

Do not include Locum Tenens Provider in this application.
You must fill out the primary provider, but any additional providers can be added by attaching your provider roster.

Provider Roster

Provider #1

First Name

Middle Name

Last Name

Date of Birth

Gender

Degree(s)

Provider Type

NPI

Medicaid Prism ID #

CAQH Number

Specialty(ies)

Areas of Interest

Languages other than English spoken fluently by provider

Describe Hospital Admitting Privileges or Admit Plan

If provider has more than one location, specify the primary location and additional practice location(s)

Provider agrees University of Utah Health Plans may share provider application and related credentialing information with any group or entity that has delegated or contracted with U of U Health Plans to provide such activities on their behalf. Information cannot be shared for any reason except for provider directory/demographic and credentialing activities.

U of U Health Plans does not discriminate based on race, gender, nationality, age, sexual orientation, the type/cost of treatment or patient in which the provider specializes including providers serving high-risk populations, or in terms of participation, reimbursement, or indemnification, against any health care professional who is acting within the scope of his, her or their license or certification under state law, solely on the basis of the license or certification.

Organizational/Provider Contracting Application

University of Utah Health Plans Provider Networks

Sender Information

Organization Information

Contracting Contact Information

Credentialing Contact Information

Location(s)

Primary Location

Location Information

Billing Information

Does the location provide any of the following?

Provider(s)

Provider #1