PEHP requires review by Medical Case Management for medical necessity and possible coordination of benefits for procedures and/or devices.
Certain medical services including some in-patient hospital admissions and all in-patient rehabilitation admissions require preauthorization before being eligible for payment. The PEHP Prauthorization team appreciates the assistance that providers offer to our members by helping with this process. Clincials will be requested for admissions that require preauthorization and the provider will be notified within 5-7 working days.
Authorizations for in-patient treatment may be an elective or emergency admission. Preauthorizations relate to length of stay. Clinical notes and information are required from the hospital. Preauthorizations DO have an option to change the Dates of Service.
The following services require written Preauthorization:
Clinicals and requests for preauthorization maybe faxed to 801-366-7449.
When multiple surgical procedures are done during the same operative session, the primary procedure is payable at 100% of the Fee Schedule. Each additional eligible procedure done is payable at 50% of the Fee Schedule. Certain procedures are considered incidental and are excluded.
To obtain patient eligibility, benefits, and general claim status, providers must login to the secured provider site at www.pehp.org. If your office doesn't have login credentials, enroll by downloading the trading partner agreement (ETPA), executing the last page, and returning the entire document to your provider relations specialist. Upon receipt of the agreement, you will be sent an assigned user ID and password.
You’ll need the following after you have successfully logged in:
Note: Not all benefits are listed. If you need additional benefits that aren’t provided, please call our Customer Service Department at 801-366-7555. Make sure to have the patient’s ID number, name, date of service, DX, CPT code, and type of visit and/or procedure to be done.
Note: Once you’ve checked on your claim online and still have lingering complex questions, please call our Customer Service Department at 801-366-7555.
Healthcare Fraud is an intentional deception or misrepresentation that the individual or entity makes, knowing that the misrepresentation could result in some unauthorized benefit to the individual, entity, or to some other party.
It is speculated that between 10% and 20% of the dollars paid by insurance companies could be attributable to Healthcare Fraud and Abuse. False claims can be divided into two categories: fraudulent and abusive.
Public Employees Health Program has established a Special Investigative Unit comprised of a Special Investigator, Provider Relations Representative, Claims Review Representative, Finance/Healthcare Analysis Representative, Claims Representative and a Case Management Representative. The SIU duties include desk and on site audits, providing internal and external fraud and abuse training, and preparation of information for criminal investigations. Investigations include providers with aberrant billing practices to determine if the practice constitutes over-utilization or fraud and includes member eligibility fraud and prescription abuse.
When the SIU staff discovers a pattern of fraudulent, abusive, or inappropriate billing practices, they will take appropriate measures to stop the activity. Claims may be denied and refunds requested for previously processed claims. Cases may be referred to the Utah Insurance Fraud Division for investigation and possible prosecution.
Please report suspected fraudulent activity to PEHP by calling 801-366-7529. You may remain anonymous.
Examples of fraudulent, abusive, or inappropriate billing for services
As of January 1, 2015, PEHP requires all contracted medical providers to submit their claims electronically. This includes COB claims. PEHP currently sends and receives healthcare transactions through the Utah Health Information Network (UHIN) or through a number of other clearinghouses and billing services that submit through UHIN.
Providers who wish to send and receive electronic healthcare transactions themselves and not through a clearinghouse will need to contact UHIN at 801-466-7705 to establish a Trading Partner Number (TPN). The TPN will be used for all payers that accept claims through UHIN. Once the TPN has been established, contact our EDI Department at 801-366-7544 or 800-753-7818, to be set up in our system and arrange testing.
Furthermore, PEHP is happy to announce that your office can send electronic claims through our website. Therefore, a clearinghouse and/or UHIN are not needed. It is through the secured portion of our website. If you do not currently have login credentials, contact your Provider Relations Specialist to get set up today!
Additionally, when a new provider is added to your practice, contact your Provider Relations Specialist to add the new provider to the correct TPN, in order to avoid claim rejections. We will need to know the provider(s), demographic information, individual NPI, TIN and TPN or clearinghouse.
PEHP only accepts paper claims for the following:
The following is required for paper submission:
PEHP accetps the UB-04 or HCFA-1500 claim form.
Coordination of Benefits
Processing / Turn Around Time
PEHP contracts with many different Employer Groups; therefore, there is no specific time frame. The claims turnaround time is based on the Employer Group that your member is with. Please note, paper claims turnaround time is longer than if the claim was submitted electronically, as electronic claims have first priority.
Contracted Providers - Claims are always paid directly to Contracted Providers
Non-Contracted Providers - PEHP shall pay claims directly to the member.
Please submit all claims to:PEHP
If a provider disagrees with how a claim was processed, provider may dispute the claim referring to the steps listed below:
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, Utah 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.