Orchard - Unchanged

Appeals

If a provider disagrees with how a claim was processed, provider may dispute the claim referring to the steps listed below:

  • Disputed Claim– Within 180 days after PEHP’s initial determination, Provider may request a full and fair review by writing to the Appeals and Policy Management Department. Upon written request, including receipt of any pertinent additional information or comments, the Benefits Resolution Department will commence an investigation. This process occurs whether an appeal form is attached with the original request or not. Upon receipt of the Benefits Resolution Department determination, the Provider will be given instruction on how to request a review by the Provider Dispute Review Committee. Please follow the instructions exactly and make sure to note the specific time period that the request must be submitted by.
  • Hearing Officer Appeal – If denied by the Provider Dispute Review Committee, Provider has 30 days from denial, to send in a written petition with the hearing officer, in accordance with the procedure set forth in Utah Code Ann. §49-11-613. Provider will file using a form provided by URS. For more information download How to Petition the Retirement Board. PDF file
  • Court of Appeals – If you disagree with the hearing officer’s decision, Provider may petition the Board for reconsideration or appeal directly to the Utah Court of Appeals within 30 days.

Note: The board packet is sent to the person who sent the original appeal

Direct your initial written requests to:

PEHP Appeals and Policy Management Department
P.O. Box 3836
Salt Lake City, UT 84110-3836
By fax: 801-320-0541

Note: If a provider wants to represent a member in the appeals process, the member must designate the provider as an Authorized Representative. The member must complete an “Appointment of Authorized Representative” and PEHP requires a “Member/Provider Appeal Filing Form” also be completed at the time of appeal.

The Appeals Claims Process, Appointment of Authorized Representative form (not required), Member/Provider Appeal Filing Form, and Member Record Release Consent Forms (only required if the Provider is representing the member as described above, and if the appeal determination involved medical judgment as required by federal law) are available at the secure PEHP for PROVIDERS site.

There are distinct differences in how Member and Provider appeals are processed.