Health Choice Utah and University of Utah Health Plans Provider Application

This common provider network application is used by Health Choice Utah and University of Utah Health Plans. For ease of administration, provider demographic information and credentialing processes are combined; however, network participation and contracting are determined separately.

Health Choice Utah Provider Network

Indicate if you are interested in participating with Health Choice Utah:

Health Choice Utah – A Medicaid physical health network available to eligible Medicaid members throughout the entire state of Utah and behavioral health network available to eligible Medicaid members in Davis, Salt Lake, Utah, Washington and Weber counties.

University of Utah Health Plans Provider Networks

Indicate the networks with which you are interested in participating:

Healthy U* – A Medicaid physical health network available to eligible Medicaid members throughout the entire state of Utah. Healthy U Behavioral* – A Medicaid mental health and substance use network available to eligible Medicaid members in Davis, Salt Lake, Utah, and Weber counties. This network of behavioral health providers and organizations is combined with the Healthy U network to create Integrated Healthy U. This network is also available to eligible Medicaid members in Summit county.

*If your clinic or organization provides both physical health and behavioral health services AND you are located within the geography listed, mark both networks.

Healthy U CHIP – A statewide provider network to support the Children’s Health Insurance Program, , a state-sponsored physical and behavioral health plan for children not covered by other health insurance. Healthy Preferred – A provider network for employer groups along the Wasatch Front from Cache to Utah counties and Summit to Tooele counties. Healthy Premier – A provider network for employer groups in Utah and Southeastern Idaho. It is also available on the Utah Individual Marketplace Exchange. U Health Plus – A narrow commercial provider network oﬀered within Salt Lake and Davis counties.

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, please contact Jessie.Konate@hsc.utah.edu.

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

Scope of Services

0 / 4000

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

Provider Information

Please be as accurate as possible when entering the provider information and we'll determine provider eligibility.

If you want to contract as a solo provider, please select Solo Provider.
If you want to contract as a new group/clinic, please select Group/Clinic.
If you want to contract as a facility, please select Facility.
(Examples of facilities include hospitals, ASCs, home medical supplies/DMEs, home health & hospices)

Complete this form as a...

Solo Provider

Group/Clinic

Facility

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

Organization Questions

Practice licensed to operate in state?

Yes

Is Practice Accredited?

Yes

Is group hospital based only?

Yes

Does Practice submit claims electronically?

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)

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.

If you do not receive confirmation of your application within 48 hours, please contact providercontracting@hsc.utah.edu

Health Choice Utah and University of Utah Health Plans Provider Application

Health Choice Utah Provider Network

University of Utah Health Plans Provider Networks

Sender Information

Provider Information

Organization Information

Organization Questions

Contracting Contact Information

Credentialing Contact Information

Location(s)

Primary Service Location (Location where patients are treated)

Location Information

Location Address Information

Billing Information

Does the location provide any of the following?