Medical and dental claim appeals
Upon receiving a denial for a medical or dental claim, carefully review the denial reason code on the remittance advice (RA) to determine the appropriate next steps. Depending on the denial reason, you may need to file an appeal, provide additional certification information or submit medical records via the provider portal. The HealthChoice internal appeals process grants providers the right to request a reconsideration. Appeals must be submitted within 180 days from the date of the original RA.
To submit your appeal through the provider portal, select Claim appeal submission, then follow the steps to log in and submit the records. All claim editing denials, including those with modifiers 25 and 59, must be appealed for reconsideration.
Appeals can also be submitted in writing to the address below. Your written request should clearly indicate what is being appealed and include all applicable documentation.
HealthChoice Appeals Unit
P.O. Box 30546
Salt Lake City, UT 84130-0546
If the initial denial is upheld, providers can submit a second-level appeal, provided additional information is available for review. Second-level appeals are only available to network providers. If you are eligible for a second-level appeal, it must be filed within 90 days from the date of the first-level response. Follow the directions listed on the adverse determination.
If you need assistance or have questions, contact Customer Care toll-free at 800-323-4314.
Pharmacy prior authorization and appeals
Prior authorization is required for certain medications to be covered by HealthChoice and for tier exceptions. The prior authorization process helps establish that a particular case meets clinically driven, medically relevant criteria before HealthChoice will approve the medication for coverage at the appropriate tier.
For more information on requesting a prior authorization, view the pharmacy benefits section of this page.
If a prior authorization is denied, submitting a first-level appeal may be appropriate. Providers will receive written notification via fax, and members will be notified within 24 to 48 hours. The notification will include information on how to appeal the denial.
If the first-level appeal is denied, directions to file a second-level appeal are provided within the denial letter, or the appeal can be faxed to 405-717-8925.
For information regarding network pharmacies and medication lists, call the pharmacy benefit manager toll-free at 877-720-9375.