If a provider disagrees with how a claim was processed, provider may appeal the claim referring to the steps listed below:

• Benefits Review Appeal

  – Within 180 days after receiving denial, Provider may request a full and fair review by writing to the Benefits Review Committee.

• Administration Appeal

  – Within 60 days of denial by Benefits Review, Provider has the right to request an Administrative Review. Upon written request, including receipt of any pertinent additional information or comments, the Administrative Review Committee will commence an investigation.

• Executive Appeal

  – If denied by Administration, Provider may within 60 days, file a written petition the URS Executive Director. Include the facts, the remedy you want, and the basis in law or equity that warrants it.

• Hearing Officer Appeal

  – If denied by the Executive Director, Provider has 30 days from denial, to send in a written petition with the hearing officer, in accordance with the procedure set forth in Utah Code Ann. §49-11-613. Provider will file using a form provided by URS. For more information download a brochure How to Petition the Retirement Board.

• Court of Appeals

  – If you disagree with the hearing officer’s decision, Provider may petition the Board for reconsideration or appeal directly to the Utah Court of Appeals within 30 days.

Direct your initial written requests to:

Electronic Submission

Providers are strongly encouraged to submit claims and receive remittances electronically. PEHP currently sends and receives healthcare transactions through the Utah Health Information Network (UHIN) or through a number of clearinghouses and billing services that submit through UHIN.

Providers who wish to send and receive electronic healthcare transactions themselves and not through a clearinghouse will need to contact UHIN at 801-466-7705 to establish a Trading Partner Number. The Trading Partner Number will be used for all payers that accept claims through UHIN. Once the Trading Partner Number has been established, please contact the EDI department at PEHP, 801-366-7544 or 800-753-7818, to be set up in our system and arrange testing.

When a new provider is added to your practice, please contact the EDI department to add the new provider to the correct Trading Partner Number to avoid claim rejections. We will need to know the Trading Partner Number as well as the individual NPI number.

After the set up and testing is complete, providers can then send their claims electronically to PEHP.

Paper Submission

Accepted Forms	Claims need to be sent on appropriate claim forms: UB-04 or HCFA-1500
Required Information for Claims Submission	Codes: The CPT (Current Procedural Terminology) HCPCS (Health Care Financing Administration’s Common Procedural Coding System) ICD-9 (International Classification of Diseases) NDC # (National Drug Code) – if applicable Charges: Provider’s charge must be provided
Coordination of Benefits	PEHP currently does not accept COB claims electronically. Please submit these types of claims paper, with the appropriate Explanation of Benefits attached. Please note, COB claims will take longer for processing, due to mailing, scanning, review, processing etc.
Processing / Turn Around Time	PEHP contracts with many different Employer Groups; therefore, there is no specific time frame.  The claims turnaround time is based on the Employer Group that your member is with.  Please note, paper claims turnaround time is longer than if the claim was submitted electronically, as electronic claims have first priority.
Payments	Contracted Providers -Claims are always paid directly to Contracted Providers Non-Contracted Providers -PEHP shall pay claims directly to the member, unless provider accepts assignment
Claims Address	Please submit all claims to: PEHP Claims Division 560 E 200 S Salt Lake City, Utah 84102-2004

Healthcare Fraud is an intentional deception or misrepresentation that the individual or entity makes, knowing that the misrepresentation could result in some unauthorized benefit to the individual, entity, or to some other party.

It is speculated that between 10% and 20% of the dollars paid by insurance companies could be attributable to Healthcare Fraud and Abuse. False claims can be divided into two categories: fraudulent and abusive.

Public Employees Health Program has established a Special Investigative Unit comprised of a Special Investigator, Provider Relations Representative, Claims Review Representative, Finance/Healthcare Analysis Representative, Claims Representative and a Case Management Representative. The SIU duties include desk and on site audits, providing internal and external fraud and abuse training, and preparation of information for criminal investigations. Investigations include providers with aberrant billing practices to determine if the practice constitutes over-utilization or fraud and includes member eligibility fraud and prescription abuse.

When the SIU staff discovers a pattern of fraudulent, abusive, or inappropriate billing practices, they will take appropriate measures to stop the activity. Claims may be denied and refunds requested for previously processed claims. Cases may be referred to the Utah Insurance Fraud Division for investigation and possible prosecution.

Please report suspected fraudulent activity to PEHP by calling 801-366-7529. You may remain anonymous.

Examples of fraudulent, abusive, or inappropriate billing for services

• Filing claims for services not provided.
• A pattern of billing that includes submitting incorrect or misleading diagnostic or procedure codes, which leads to incorrect processing services.
• Billing for more expensive service than was actually performed (upcoding).
• Advertising free or discounted services, then billing PEHP for additional services that may or may not be medially necessary.
• Billing for services or treatment performed on a family member, even those with different last names.
• Submitting claims for charges that, in the absence of the member’s insurance, there would be no obligation to pay; services provided by a family member (It is inappropriate to bill for services that, in the absence of insurance coverage, would become “professional courtesy,” i.e., for members of your staff and members of your group practice and their families.).

To enroll, please download the Trading Partner Agreement (ETPA), fill out the last page and return the entire document to your Provider Relations Representative. Upon receipt of the Agreement, you will be assigned a User ID Number and a password. After that, you can login to the PEHP for Providers web site.

How to obtain Benefits / Eligibility / Claims through Customer Service

To obtain benefits, verify eligibility or check claims status, you must contact Customer Service at one of the following numbers:

Please make sure you have the following information ready.

To Obtain benefits:

• Subscriber ID number
• Patient name
• Date of service (if available)
• Diagnosis
• Type of visit or procedure to be done

To Obtain Eligibility:

• Subscriber ID number
• Patient name
• Date of service

To Check the Status of a Claim:

• Subscriber ID number
• Patient name
• Date of service
• Provider of service

When multiple surgical procedures are done during the same operative session, the primary procedure is payable at 100% of the Fee Schedule. Each additional eligible procedure done is payable at 50% of the Fee Schedule. Certain procedures are considered incidental and are excluded.

Requires review by Medical Case Management for Medical Necessity and possible coordination of benefits for procedure or device.

The following services require written Pre-authorization

• Dental procedures performed in an outpatient facility for patients 6 years of age and older.
• Organ or tissue transplants
• Surgery that may be partially or wholly Cosmetic
• Coronary CT angiography
• Implantation of artificial Devices
• New and Unproven technologies
• Cochlear implants
• Genetic testing
• Durable Medical Equipment with a purchase price over $750 or any rental of more than 60 days
• Home fetal monitoring
• Botox injections
• Maxillary/Mandibular bone or Calcitite augmentation Surgery
• All out-of-state, out-of-network surgeries/procedures or inpatient admissions that are not Urgent or Life-threatening
• Pelvic floor therapy
• Wound care, except for the diagnosis of burns
• Home health and Hospice Care
• Hyperbaric oxygen treatments
• Intrathecal pumps
• Spinal cord stimulators
• Surgical Procedures utilizing robotic assistance
• Lymphedema therapy after 10 visits
• Implantable medications, excluding contraception
• Certain prescription and Specialty Drugs
• Continuous glucose monitoring Devices and supplies
• Jaw surgery
• Dialysis when using non-Contracted Providers
• Breast pumps
• Human pasteurized milk
• Physical or occupational therapy after 16 combined visits
• Speech therapy
• Stereotactic radio surgery
• Magnetoencephalography (MEG)/ magnetic source imaging
• Voice therapy

Pre–Notification (Pre–Note)

Authorizations for in-patient treatment may be an elective or emergency admission. Pre-notes relate to length of stay. Clinical notes and information are required from the hospital. Pre-Notes DO have an option to change the Dates of Service.

The following services require written Pre-Notification:

• In-Patient Hospitalization
• Skilled Nursing/Rehab Stays

Clinical and requests for Pre-authorization and Pre – Notification maybe faxed to 801-366-7449