Appeals

If a Provider believes PEHP has made an error in processing a claim or making a decision, the Provider may appeal as follows:

• First-Level Appeal - A written appeal must be completed in full, signed by the Provider or their representative, and filed within 180 days of a claim’s adjudication. 

An appeal must also:

• Identify with specificity PEHP’s error in processing a claim or making a decision
• Include relevant documentation and identify the page number and sections that support your position
• Detail how the claim or decision should be corrected
• Cover a single claim unless the same error, same documentation, and same correction apply for bundled claims.

PEHP can neither accept nor investigate a claim where a Provider has failed to provide this information. The burden of showing that an error was made and how it should be corrected rests with the Provider.  

Download First Level Appeal Form

To assist Providers, PEHP payment policies and common exclusions and limitations are available online.  For clarification about how a claim was processed, Providers may contact PEHP online or by calling 801-366-7555 or 800-765-7347.

• Hearing Officer Appeal – A Provider may appeal the results of a First-Level Appeal within 30 days by submitting a written petition to the Hearing Officer in accordance with the procedure set forth in Utah Code Ann. §49-11-613. The Provider will file using a form provided by URS. For more information download How to Petition the Retirement Board. 
• Court of Appeals – A Provider may appeal the hearing officer’s decision within 30 days by petitioning the Board for reconsideration or appealing directly to the Utah Court of Appeals.

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

Direct your First-Level Appeal 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.