MHC Appeal FormPlease Note: Use this form if you are contacting us about a denied claim (e.g. timely filing, nonparticipating provider) or a denied service. For other complaints, please use the MHC Customer Complaint Form.
If you need help filling out this form, call us at 855-447-2900. (Si necesita ayuda para llenar o completar este formulario, llamenos al 855-447-2900.) If you are deaf or hard of hearing, you can call Utah Relay Services at 711 or 1-800- 346-4128. (Si habla español, puede llamar a Spanish Relay Utah al 1-888-346-3162.) These are free public telephone relay services or TTY/TDD. (Estos son servicios gratuitos de retransmisión telefónica pública o TTY / TDD.)
If you called us to file an appeal, a Customer Advocate can file a written appeal on your behalf, if you give verbal consent. If you do not give verbal consent, you must send this form to us within 5 business days from your call or the appeal will be closed. You will need to send a new appeal. You still have the right to appeal for 180 days from the date on the Notice of Action.