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