Health CO-OP University of Health Plans

MHC Appeal Form

Please 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 of 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.

I give my verbal consent for this request to be considered a written appeal. I agree this information is correct and complete to the best of my knowledge.
Member Information
Are you the provider, the member, or a MHC Customer Service Representative?
Provider Information
Appeal Information
Is this an appeal for:
If your appeal is for a denied or reduced service (e.g., benefits are being reduced for home health care), do you have an urgent health need or is your life in danger? Would you like to ask for a quick review?   (If we agree you need a quick review, we will make a decision on your appeal within 3 business days.)
If your appeal is about a service you get that is ending or being reduced do you want to get the service during the appeal review?

You can choose to keep getting service(s) during your appeal but you might have to pay for them if we do not decide in your favor.
   
You have the right to submit comments, documents or information relevant to the appeal. Do you have more information you would like to send for the appeal? You can attach records below.
   
Upload File
You can fax the information to the MHC Appeals Team at the fax # 801-281-6121.

You may mail the information to:
MHC C/O UUHP Attn: Appeals Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107

The information must be received within 5 business days or the appeal is not complete. We will close the appeal. You still have the right to appeal within 180 days from the date on your Notice of Action.