University Health Plans - University of Utah Health Care - Salt Lake City, Utah

MDOC Denial Medical Record Submission

Did you receive a denial code (252 and/or M127) for missing medical documentation (MDOC)? Please only use this form in response to 252 and/or M127 denial codes.
Note: This form and fax line is not to be used for any other documentation submission.

* Required Fields
Claim Information
Todays Date: 4/15/2024


If documentation is required for both Medical and Pharmacy lines on claim then please submit a form for Medical and Pharmacy separately with the same claim number.

Provider Information
Member Information
Upload File(s)