Who is My Provider Representative?

PEHP does not have designated provider representatives. You have a whole department available to address your concerns. Call the Member and Provider Service Center at 801-366-7555. You can also send us a message via your PEHP provider portal.

12/27/22

How do I contract with PEHP?

To view the credentialing requirements and apply, visit Pehp - Contracts/Credentialing.

12/27/22

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

PEHP does not release the credential status over the phone or by email. If you’re the local office administrator for an office/facility, log in to your PEHP Classic Account, select provider from the drop- down menu, and scroll to the bottom of the main menu page to see all the networks the provider is contracted on and effective dates.

12/27/22

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

You don’t need to add practitioners to the New Provider portal. Your account is tied to the Supplier (TIN), so you see all claims processed under that supplier. Log in to the New Provider Account and search claims by date of service and patient. Use the Classic Account to verify if individual practitioner is enrolled. You can view all supplier, supplier location and practitioner accounts when searching eligibility or claims.

12/27/22

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

How do I add office users to my New Provider Portal?

Only the main office contact for your practice is allowed to create an initial account. Once the main office contact has created an account, they can add admin users for specific roles. See how to create an account and add other users on page 3 of the Provider User Guide. Note: If your practice created multiple main user accounts, you’ll have to remove them and add them separately using the instructions on page 3 of the Provider User Guide. Please do not delete the main office contact account.

4/3/23

How do I view remittance advice also known as Explanation of Payment (EOP) for a claim in the New Provider Portal?

To view an EOP for a claim, log in to the New Provider Account and choose Office Management--> Communications Archive from menu on top. Next, choose a provider from your office and “EOP” from the Document Type drop-down menu. Note: Make sure to select the provider entry with the Supplier number “S000xxx” (not the Supplier Location or Practitioner number).

If you don’t see a remittance advice/EOP for a past claim, please send us a message via the Message Center.

4/3/23

How do I check the status of an appeal in the new Provider Portal?

To check the status of an appeal, log in to your new Provider Portal. From the homepage, go to the Authorizations section on the bottom, and click on Advanced Search.

4/3/23

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

• If you’re locked out of the Classic Portal, please call 801-366-7555

• If you’re locked out of the New Portal, please call 1-877-814-9909

4/3/23

How do I update my demographic information?

To update your name, address, phone number, or other demographic information please complete the Provider Account Information form and return to us via email: providersubmissions@pehp.org.Note: Do not fill out this form if you work under a new TIN.

10/4/23

How do I contact PEHP?

The best way to contact PEHP is via the Message Center in your New Provider Account. If you need to call us, please call 801-366-7555. Note: Call volumes are higher than normal as we transition members to our new system. Please consider calling on Fridays between 8:00 a.m. - 10:00 a.m. and 4:00 p.m. - 5:00 p.m. If you have questions regarding your EDI transactions, or for Trading Partner Number changes, please call the EDI department at 801-366-7544.

4/3/23

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

No, this is not allowed under our contract terms. Accepting payment from a member for a claim submitted to PEHP creates complications for the member, the provider, and PEHP in terms of payment and accounting. It is essential to adhere to the contractual terms to ensure a smooth claims process.

8/4/23

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

Are you an Out-of-Network (OON) provider who needs to submit claims?

If you're an OON provider serving PEHP members and need to be added to our system to submit claims via our website or your preferred clearinghouse, please fill out the Provider Account Information form.

Here are the types of claims PEHP will accept by paper.

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