- Please use the Customer Appeal Form to appeal an adverse benefit determination (denied or limited authorization request) or a claim benefit denial where the member could be liable for payment.
- 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 Provider Disputes of claim billing denials or contract payment amounts, please use the Provider Dispute Form.
- For any other concerns, complaints or grievances, please use this form.
If you need help filling out this form, call us at: (Si necesita ayuda para llenar o completar este formulario, llamenos al:)
- Medicaid: 801-213-4104 / 1-833-981-0212
- CHIP: 801-213-0525 / 1-833-404-4300
- Commercial: 801-213-4008 / 1-833-981-0213
- Individual: 801-213-4111 / 1-833-981-0214
- Employee Plan: 801-213-0274 / 1-833-443-3440
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.