University of Utah Health Plans Appeals Form

Please Note: Use this form if you are contacting us about a denied claim (e.g. timely filing, nonparticipating provider) or a denied service. For other complaints, please use the Customer Complaint Form.

If you need help filling out this form, call us at 801-587-6480 or 1-888-271-5870. (Si necesita ayuda para llenar o completar este formulario, llamenos al 801-587-6480 o 1-888-271-5870). If you are deaf or hard of hearing, you can call Utah Relay Services at 711 or 1-800- 346-4128. Si habla español, puede llamar a Spanish Relay Utah al 1-888-346-3162. These are free public telephone relay services or TTY/TDD. Estos son servicios gratuitos de retransmisión telefónica pública o TTY / TDD.


If you called us to file an appeal, a Customer Advocate can file a written appeal on your behalf, if you give verbal consent.


Member Information

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



Provider Information


Insurance Product


Appeal Information





Appeal Documents


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

You may mail the information to:
Appeals Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107

The information must be received within 5 business days or the appeal is not complete. We will close the appeal. You still have the right to appeal within 180 days from the date on your Notice of Action.