Provider Dispute Form

Please Note: Use this form if you are a Contracted Provider contacting us about a denied claim for billing issues such as timely filing, coding errors, or your claim payment amount or a claim denial for not medically necessary services.
Please use the 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.

Request Type:

Select One New Provider Dispute Submission Additional Information for an Existing Dispute

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

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Member Information

Member Name:

Member ID Number:

Member Street Address:

Member 2nd Street Address:

Member City:

Member State:

Select One 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:

Member Plan:

Select One Medicaid - Healthy U Utah Individual Marketplace Mountain Health Co-Op Commercial Employer Plan Health Choice

Provider Information

Name of Provider Involved:

Provider Correspondence Address:

Provider Correspondence City:

Provider Correspondence State:

Select One 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 Appeal Correspondence Zip Code:

Provider Phone Number:

Fax Number:

Provider NPI:

Case Information

Type of Service:

Select One Medical Medical Pharmacy Medication Behavioral Health

Medication

Name of Person Submitting Appeal:

Phone Number of Person Submitting Appeal:

Date(s) of service you are appealing:

Prior Authorization Number (if applicable):

Claim Number(s) (if applicable):

Appeal Reason (Please Be Specific and Include Details):

Supporting Documents

Select file #1: clear Select file #2: clear Select file #3: clear Select file #4: clear Select file #5: clear

If you would prefer to fax the information to the Appeals Team, please use fax # 801-587-9985.

If you would prefer to mail the information to the Appeals Team, please use:
Appeals Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107

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