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

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

12/27/22

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

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 Portal 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

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

• 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

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

To view an EOP for a claim, log in to the New Provider Portal 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).

Important! Please allow up to 24 hours after receiving your 835/EOP electronic deposit for it to appear in the new portal. If you don’t see it online after 24 hours, please contact us via the Message Center. Please do not return payments you cannot identify without first reaching out to us to validate the payment.

5/22/25

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

• 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

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

The best way to contact PEHP is via the Message Center in your New Provider Portal. 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

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

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

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

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

Physical therapy and Occupational Therapy shall be reimbursed at a rate of a maximum of $90.71* per diem (per day) for all services provided regardless of the services or number of modalities provided for dates of service prior to July 1, 2025. After July 1, 2025, the new per diem is $91.16.

Contracted providers are obligated to accept this amount as allowed in full and may not balance bill member.

For services not included in the per diem maximum, i.e. E&M, labs, x-rays, etc., provider shall be compensated an amount (less applicable co-payments, coinsurance, and/or deductible) equal to the lesser of the billed amount or the allowed amount as determined by PEHP and indicated on the EOB and Provider Remittance.

Providers may download their Fee Schedule at PEHP for Providers*.

*Please be advised the Fee Schedule will show allowed amounts on the individual code. Should an amount for any one code be less than the per diem on its own, or when billed with additional codes whose allowed amounts, when combined, are less than the per diem, PEHP will apply the full allowed amount to that code(s). Otherwise, all codes will be combined with the allowed amount not to exceed the per diem rate.

08/08/25

Anesthesia Reimbursement Rates effective July 1, 2024 to current (Per 12-Minute Unit):

• MD’s (Anesthesiologists): $68.53*

• CRNA’s (Certified Registered Nurse Anesthetists): $63.18*

*These rates are based on current community-based anesthesia conversion factor. However, some providers may have different rates based on their specific group contract.

Sample calculation for Time-Based Anesthesia Reimbursement:

Based Unit + Time Units + Modifier Units + Physical Status Units (if applicable) X Conversion Factor.

• Base Unit: Represents the base unit value of the complexity of the service, and includes the preoperative, anesthesia procedure, and post-operative.

• Time Unit: Represents the time spent providing anesthesia, which we allow in 12-minute increments.

• If only total time is provided (not time units), divide the total time by 12 to determine the number of time units.

• Any remaining portion (even if less than 12 minutes) is counted as one full unit.

Sample calculation for Non-Time-Based Procedures:

• For procedures not based on time, reimbursement is calculated using the CMS Resource-Base Relative Value System (RBRVS) for Utah.

Sample calculation Example Using Based Units:

Based Units: 5 Time: 45 minutes = 4 time units

• 3 full units (12 x 3=36 minutes)

• 1 unit (remaining 9 minutes)

Modifier Units: 1

Physical Status Units: 1

Conversion Factor: $XX.XX – Total Reimbursement

ASA = American Society of Anesthesiologists

RVU = Relative Value Unit: are standard units that place a value to each unit of service assigned to each CPT code.

08/29/25

How does the PEHP.org New provider portal Message Center work?

Log in. Click Message Center at top of screen. Click the box that shows your name and “Access” under Relationship. Click New Message. Click Add Recipient and direct message to box that fits your needs based off the following criteria:

• Dental Pre-Authorization: Send pre-determination forms for TACS and HRP dental.

• Form Submission for Demographic Add, Change or Delete: Send Add to Group Forms, Demographic Update Forms, etc. *Rosters need to be sent by e-mail to providersubmissions@pehp.org

• Medical Pre-Authorization: Send medical pre-auth forms for TACS and HRP.

• Provider Appeals: Send provider appeal forms for TACS and HRP.

• Question – Claims/Payment: Send questions regarding understanding claims denials, processing, payments, recoupments etc. as well as submit eligible documents such as requested medical records. Submissions to this box are deemed paper and will only be accepted if eligible to be submitted by paper as listed here: PEHP - Paper Claims Submission

• Questions – Web, Form Status & General: Send requests on forms status, issues or help either website, and any other question not covered by existing message center boxes.

• Request for Missing EOP/835: Send requests for assistance locating Missing EOP’s or not receiving 835 files.

08/29/25