University of Utah Health Plans Customer Complaint 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, partially authorized or reduced services, please use the Customer Appeal Form. For other complaints, please use this 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.

Request Type:

New Additional Information

Please provide the identification number of the main request or other information to associate the requests.   *

Priority

Routine Expedited

Reporting Department:

Medical Behavioral Health Pharmacy

Member Information

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

I am the:

Provider Member UUHP Customer Service Rep Vendor AOR - Authorized Representitive for the Member. (Please ensure that you have a signed AOR/Consent form) Facility

Your Name, if Not the member:

SubmitterPhoneNum

Member Name:

Member ID Number:

Loading---

Member Street Address:

Member 2nd Street Address:

Member City:

Member State:

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Member Zip Code:

Member Phone Number:

Provider Information

Provider NPI:

Name of Provider Involved:

Provider Street Address:

Provider City:

Provider State:

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Provider Zip Code:

Provider Phone Number:

Provider Specialty:

Health Plan Product

Health Plan:

Healthy Advantage Healthy Advantage Plus Healthy Preferred Healthy Premier Healthy U MHC University Health Care Plus

Complaint Information

Date(s) of service related to complaint:

Claim Number(s) if applicable:

Referral number if applicable:

CSR number (for UUHP Representatives only):

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

Upload File

Select file #1:

Select file #2:

Select file #3:

Select file #4:

Select file #5:

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

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

---