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.
 Yes     No   
Member Information
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:
Provider Information
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:
Appeal Information
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 72 hours.)
 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?
 Yes
 No   
You can attach records below.

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 # 801-281-6121.

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.