Health Insurance for Montana | Montana Health CO-OP

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. Yes
No

Are you the provider, the member, or a MHC Customer Service Representative? Provider
Member
MHC Customer Service Representative

Your name, if not the member:

Member Name:

Member ID Number:

Member Street Address:

Member 2nd Street Address:

Member City:

Member State:

Member Zip Code:

Member Phone Number:

Name of Provider Involved:

Provider Appeal Correspondence Address:

Provider Appeal Correspondence City:

Provider Appeal Correspondence State:

Provider Appeal Correspondence Zip Code:

Phone Number Of Person Submitting Appeal:

Provider Specialty:

Date(s) of service you are appealing:

Claim Number(s) if applicable:

Referral number if applicable:

CRM number (for MHC Representatives only):

Appeal Reason (Please Be Specific and Include Details):

Is this an appeal for: Denied Claim
Denied Service

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? Yes (If we agree you need a quick review, we will make a decision on your appeal within 3 business days.)
No

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. Yes, I want to keep getting the service(s). I know that I may have to pay for the service(s) if the appeal decision is not in my favor.
No, I do not want to keep getting the service(s).

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. Yes
No

Select file #1: Select file #2: Select file #3: Select file #4: Select file #5:

You can fax the information to the MHC Appeals Team at the fax # 801-587-9985.

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.

MHC Appeal Form