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801-366-7555/800-765-7347 or Message Center in the Provider Portal

Member & Provider Service Center

Our Customer Service Representatives are here to help with questions about claims, member eligibility, benefits, and general Master Policy information. For faster service, contact us via the Message Center in your PEHP account. See how.

Inpatient Prenotification and Outpatient Preauthorization

All inpatient medical services require prenotification including mental health/substance abuse services. Inpatient prenotifications can be initiated by calling the number above (for Jordan School District, please call the Blomquist Hale Consulting Group directly at 801-262-9619 or 800-926-9619). Certain Outpatient and Pharmacy services require preauthorization. If you are referring or providing any such service for a PEHP member, please call the number above to initiate the authorization review process.

Case Management

Our Case Managers assist members with acute conditions by helping them find economical ways to meet their healthcare needs without compromising quality of care. Provider referrals are welcome.

EDI Helpdesk

Our EDI Helpdesk answers detailed EDI questions including testing and rejection codes. The Helpdesk also sets up providers for EDI and adds them to existing trading partner numbers, provides payer IDs, and addresses EDI related issues for claim submission and payment. They can be reached directly at 801-366-7544 or 800-753-7818.

Need to Escalate an Issue?

Most questions can be answered using the Provider Portal Guide and FAQ below or by calling the Member & Provider Service Center at 801-366-7555. If you still need help or have an issue that needs immediate attention, a Provider Specialist can assist with specific escalated concerns. See how to contact a Provider Specialist below.

FAQ
Need to Escalate an Issue?
Who is Your Provider Specialist?
How to Escalate an Issue
Not Contracted/Out-of-State Issues
Provider Portal Issues
Contracts & Credentialing Issues
Fee Schedule Issues
Issues with Provider Form Updates
Claims Submission Issues
Claims Processing Issues
Payment Issues

FAQ

Who is My Provider Representative?

How do I contract with PEHP?

How do I get Credential/Eligibility/Contract status of individual doctor?

PEHP is updating our New claims system and only updating Classic as needed to process claims from dates of service before 9.1.25. To validate a provider has been added to your roster and is active, you will need to load a report on the pehp.org New provider portal.

A user with the role local administrator can validate a provider is added by going to Resources->Reports->Provider Report. When running the report, select the practice location, any applicable networks and hit enter. It loads all practitioners enrolled at that location on the day report is run. Load a report for all locations.

10/03/25

Do I need to add a new practitioner to the New Provider portal?

What are the requirements for submitting an appeal?

If a Provider believes PEHP has made in error in a decision or the processing of a claim, a First-Level Appeal must be filed within 180 days of the claim's adjudication.

This appeal must be completed in full and submitted to PEHP signed by the provider or provider’s representative. The provider bears the burden of showing why PEHP paid the claim in error and how the error should be corrected. As such, the provider must identify with specificity PEHP's error, provide supporting documentation, and highlight the part of each document that supports the appeal. PEHP will not accept or investigate a claim where a provider has failed to provide this information. An appeal that is not filed within 180 days or lacks specificity or documentation will be denied

Each appeal should be filed separately. PEHP will deny a bundle of appealed claims unless the appeal identifies with specificity that PEHP made the same error on each claim, what the error was, how it should be corrected, and provides supporting documentation (including highlighting) and how they support the appeal.

1/3/23

How do I know which portal to use to submit claims?

• If a PEHP member has an ID card/number that begins with 174100, submit medical claims using the Classic Portal for services until the last day of their current plan year. If you need to submit dental claims, you can submit claims via UHIN or your preferred clearinghouse. Learn more at www.uhin.org

• If a PEHP member has an ID card/number that begins with M000, submit medical and dental claims using the New Portal for services that begin on the first day of their new plan year.

• To determine the correct ID number for a PEHP member, use the Member ID Lookup Tool on the Classic Portal.

4/3/23

I'm locked out of my Provider account. Who do I contact?

How do I update my demographic information?

Can a contracted provider request a member to pay PEHP's portion of a submitted claim?

Claim submission tips to avoid payment delays

When submitting claims to PEHP via our new system or your clearinghouse (such as UHIN), please follow these guidelines to avoid payment delays:

• Box 24 (Rendering Provider/Practitioner ID #): Ensure the name spelling and NPI match accurately. Any discrepancy will result in automatic claim rejection by our new system.

• Box 32 (Service Facility Location/Supplier Location): Input the official name of your practice/facility precisely. Failure to do so may lead to unrecognized location in our new system.

• Box 33 (Billing Provider Info/Supplier Information): Verify that your company's IRS EIN/147c matches the details PEHP has on record for your correspondence and pay-to address. If your claim is rejected, please contact us to identify the specific areas that didn't align correctly with our.

10/20/23

What should I know about gag clauses?

PEHP is committed to compliance with federal law and regulations. PEHP has used its best efforts and believes that all of its provider network agreements are in compliance with Public Health Service (PHS) Act section 2799A-9.

To the extent that any provision of PEHP’s provider contracts could be construed as out of compliance, PEHP hereby disavows and treats as void any provision of its provider contracts that would directly or indirectly restrict PEHP from —

(1) providing provider-specific cost or quality of care information or data, through a consumer engagement tool or any other means, to referring providers, the plan sponsor, participants, beneficiaries, or enrollees, or individuals eligible to become participants, beneficiaries, or enrollees of the plan or coverage;

(2) electronically accessing de-identified claims and encounter information or data for each participant, beneficiary, or enrollee in the plan or coverage upon request and consistent with the privacy regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Genetic Information Nondiscrimination Act of 2008 (GINA), and the Americans with Disabilities Act of 1990 (ADA), including, on a per claim basis—

(i) financial information, such as the allowed amount, or any other claim-related financial obligations included in the provider contract; (ii) provider information, including name and clinical designation; (iii) service codes; or (iv) any other data element included in claim or encounter transactions; or

(3) sharing information or data described in (1) and (2), or directing such information be shared, with a business associate, as defined in 45 CFR 160.103, consistent with applicable privacy regulations promulgated pursuant to section 264(c) of HIPAA, GINA, and the ADA.

12/18/23

Need to Escalate an Issue?
How to Contact a Provider Specialist

Most questions can be answered using the Provider Portal Guide and FAQ online or by calling the Member & Provider Service Center at 801-366-7555. If you still need help or have an issue that needs immediate attention, a Provider Specialist can assist with specific escalated concerns.

Who is Your Provider Specialist?

Your provider specialist is assigned by alpha split using the first letter of the first word of the legal name tied to your IRS Tax Identification Number (TIN). DBA’s are not used.

Example: John Doe LLC → Your alpha split is J.

Example: Doe Jane Psychiatry PLLC → Your alpha split is D.

How to Escalate an Issue

Urgent: Call 801-366-7555 and follow the prompts to reach your Provider Specialist.

Non-Urgent: Send a message via the Provider Portal and include:

Subject: Escalation Request
Your name
Call back number & availability
Provider/Group name and TIN (required)
Provider Portal username (required)
Details of previous contacts (dates, times and phone number it came from, confirmation #s, issue #’s or escalated issue #s.
Examples of the issue (claim details, payment details, user account information etc.)

Not Contracted/Out-of-State Issues

Out-of-state facilities that do not have a clearinghouse connected to UHIN should call 801-366-7555 for assistance in submitting claims.

See how to submit claims

Escalate if:

Your question isn’t answered with the guidance provided.

Provider Portal Issues

PEHP does not create portal accounts on behalf of providers. Please review the Provider Portal Guide for step-by-step instructions on how to create an account.

Important!

The first user to create an account becomes the Local Administrator and manages all other users for that TIN.
Each username is linked to one TIN.
If you can’t create an account, your group may not be in our system. To be added to our system, submit a Provider Account Information Form or call us at 801-366-7555 for TIN verification.

Escalate if:

Your TIN exists in our system, but the previous administrator left and no one can manage accounts.
Your TIN exists in our system, but you receive errors and no admin is listed.
You want a one-on-one tutorial on using the Provider Portal.

Contracts & Credentialing Issues

What you need to know:

PEHP contracts with groups by TIN, not individual NPIs. When a group changes ownership and a new TIN is issued, a new contract is required.
Forms are available online (contracts, adds/removes, rosters). Learn more.
Mental Health Providers use the Group Medical Contract, except BCBAs who use the Individual Autism Services Agreement.
Providers should keep their own agreement copies; PEHP does not research past contracts. Local Administrators can view contract language, review current contract templates online and validate rosters by running a report via the Provider Portal under Office Management.

Escalate if:

No contract template exists for your group type online.
You have questions about contract language (not fee schedules).

Fee Schedule Issues

Fee schedules are available online via the Provider Portal under Quick Access. See how.

Fee schedules are specific to the primary taxonomy listed on that practitioner under the TIN, location, date of service and network you search.

Only codes billable for the Taxonomy of the practitioner will be viewable. If you bill a different Taxonomy than what PEHP has on file as the primary Taxonomy, the Fee Schedule Tool outcome will not match your claim outcome.

Local Administrators should confirm practitioners and their taxonomies at each location under your TIN. To do this, run a Provider Report via the Provider Portal under Office Management. The Specialty is the plain language description of the Taxonomy.

Escalate if:

Fee schedule results do not match claim allowable despite correct provider information in Provider Report.
Fee schedule won’t load despite following correct steps.
Codes you’ve billed or verified via a benefit call as allowed are missing.

Issues with Provider Form Updates

All forms (Provider Information, Add/Remove from Group, Roster, Contract Forms, Contract Termination, sign up for EFT) are available online. Learn more.

Escalate if:

You submitted required forms to the correct email (providersubmissions@pehp.org), PEHP shows them received/processed, but:

No record appears.
Portal access is still not working.
A processed form does not reflect correctly in Provider Report.
EFT updates aren’t reflected after 7 business days.

Claims Submission Issues

PEHP strongly recommends electronic billing via a UHIN-connected clearinghouse. For clearinghouses that request enrollment verification, a Local Administrator should run a Provider Report under Office Management in the Provider Portal as proof.

Paper claim submission guidelines are available online. Learn more.

What you need to know:

Portal claim submission tools (medical and dental professional claims) generate a confirmation number. Make sure to save it to research the issue if something goes awry with your submission.
Out- of-state facilities that do not have a clearinghouse that connects to UHIN should call us at 801-366-7555 for assistance in submitting claims.
Rejected claims cannot be corrected. You must submit a new claim entered as a fresh claim with no reference to the rejected claim number.

Escalate if:

A portal-submitted claim hasn’t appeared after 24–48 hours (Please provide confirmation #)
Most of your claims are Pending and you need help identifying the cause.
Multiple claims Reject and you cannot identify why.
Multiple professional claims Rejecting for ‘Missing Practitioners’ despite verification the NPI was correctly entered into boxes 24 and 33 and verified with clearinghouse that the NPI is correctly marked as NPI type 1 in the NM1 section of claim. Many clearinghouses have a base setting of type 2 which causes this issue.
Multiple claims Deny/Reject despite NDC that was submitted with verified billing format.

Claims Processing Issues

You can verify claim status and EOPs online via the Provider Portal. See how.

For denial/rejection/pending questions, contact us at 801-366-7555 or send a message via the Provider Portal.

For disagreement with a denial, submit an appeal. Learn more.

Escalate if:

Multiple claims Deny/Reject despite correctly formatted NDC for single dose.
Allowable discrepancies exist between practitioners with the same taxonomy under the same TIN billed from the same location and network.

Payment Issues

Contracted dental providers have 60 days to voluntarily refund overpayments.

For other providers, PEHP does not recommend voluntarily refunding if your office bills large numbers of claims each month. This is because with many claims in turnaround, it is likely an auto-deduction will occur within days of the overpay being identified which increases likelihood of voluntary refund being received and credited after the auto-deduction already occurred.

Escalate if:

Duplicate payments have the same draft/check number.
Payments belong to another office.
A voluntary refund is over 90 days old and not credited to your account.
EFT updates processed but payments aren’t going to the correct bank account for claims processed after 7 business days.

801-366-7555/800-765-7347 or Message Center in the Provider Portal

Member & Provider Service Center

Inpatient Prenotification and Outpatient Preauthorization

Case Management

EDI Helpdesk

Need to Escalate an Issue?

FAQ

Need to Escalate an Issue? How to Contact a Provider Specialist

Who is Your Provider Specialist?

How to Escalate an Issue

Not Contracted/Out-of-State Issues

Provider Portal Issues

Contracts & Credentialing Issues

Fee Schedule Issues

Issues with Provider Form Updates

Claims Submission Issues

Claims Processing Issues

Payment Issues

Need to Escalate an Issue?
How to Contact a Provider Specialist