Providers – Mountain Health CO-OP

Provider Resources

Contact

Questions & Support
[email protected]

Prior Authorization

Request prior auth through
the MyCare Portal for fastest processing.

Primary Prior Authorization Form (PDF)

List of Services Requiring Prior Auth

Searching for a code or procedure within the PDF list of services:

Open the PDF in a desktop browser
Press Ctrl+F on Windows or Command+F on Mac
Type the word or phrase you want to search for
Use the arrow keys to navigate between results
Press X or Esc to hide the search bar

The List of Services Requiring Prior Authorization PDF shows which CPT/HCPCs codes need approval before being covered.

It does not show codes that might be excluded from coverage or denied for other reasons.

When a code is on this list it means prior authorization is required if the service is covered.

Help with Prior Auth

How to Request Prior Auth

The best way to request prior authorization is by submitting a completed Prior Authorization form through the MyCare portal.

Processing Time

Urgent requests: 72 hours.

Standard requests: within 14 calendar days.

All required documentation must be received prior to processing.

“Urgent” is defined as:
Medical services that are needed in a timely or urgent manner that would subject the member to adverse health consequences without the care or treatment requested. Mountain Health Co-Op reserves the right to classify Urgent requests as standard requests when this definition is not met.

Documentation

To provide better patient care and to avoid delays, submit a fully completed form and complete clinical documentation.

Failure to submit required documentation may result in processing delays, the inability to establish medical necessity, and possibly a denial.

Submit all relevant documentation through the MyCare portal.

Inpatient Admissions Documentation Needed:

Admitting Orders
H&P
ED documentation
Labs
Imaging Results
Medications

Procedure/Imaging Clinical Documentation Needed:

physician notes
physical statement
detailed physical exam on affected site
radiological findings
lab results
specific indication and other pertinent information related to the request
NSAID usage
physical therapy and all other medical modalities tried – start and end time and the effectiveness of the medication, other modalities, and PT services (for imaging request)

Power or Custom Wheelchair Documentation Needed:

current wheelchair type
date of purchase and purchaser (i.e. insurance; private)
clinical evaluation by patient’s PCP addressing ambulatory ability
prognosis (in LOMN form)
Wheelchair evaluation by PT/OT within 6 months for clients 21 and older; Shriners and primary Children’s are affiliates within 3 months for under 21
Patient skills check list for power chair
barriers to transport
use/accessibility of residents have been addressed
repair history of current wheelchair (if applicable)

Retroactive Prior Authorization

Did you receive a denial code (AUT) for lack of prior authorization?

Please submit an appeal in response to AUT codes using this form.

Supporting Guides

General Criteria for MRIs

MyCare Portal, Provider User Guide

Pharmacy Prior Auth

Formulary

Nursing & Care Requests

Waiver Forms

Behavorial Requests

Appeals

Manage Your Appeals

Choosing the Right Appeal Form

Use this one for:

appeal an adverse benefit determination (denied or limited authorization request)
claim benefit denial where the member could be liable for payment.
For a medication administered to a member in a facility setting (provider or infusion center) or in the home dispensed from a home infusion pharmacy.

No data was found

Use for a medication dispensed to a member from a retail or specialty pharmacy.

General Guides

Please include all medical documentation after this completed form when submitting to the Appeals Department.

If you need help filling out the form, call Member Service at 800-299-6080.

How to appeal a decision

You may submit a completed Appeal Form using one of the following methods:

Fax (Preferred Method)
800-781-6260

Mail
Mountain Health Co-Op
PO Box 30311
Salt Lake City, UT 84130

Expedited Processing
Call 833-412-4144

Oral requests for appeals can be made by calling 833-412-4144.

Documentation

To provide better patient care and to avoid delays, submit a fully completed form and complete clinical documentation.

Failure to submit required documentation may result in processing delays, the inability to establish medical necessity, and possibly a denial.

Submitting Documentation:

Fax (Preferred Method)
800-781-6260

Mail
Mountain Health Co-Op
PO Box 30311
Salt Lake City, UT 84130

For expedited processing or oral requests for appeals, please call 833-412-4144

Inpatient Admissions Documentation Needed:

Admitting Orders
H&P
ED documentation
Labs
Imaging Results
Medications

Procedure/Imaging Clinical Documentation Needed:

physician notes
physical statement
detailed physical exam on affected site
radiological findings
lab results
specific indication and other pertinent information related to the request
NSAID usage
physical therapy and all other medical modalities tried – start and end time and the effectiveness of the medication, other modalities, and PT services (for imaging request)

Power or Custom Wheelchair Documentation Needed:

current wheelchair type
date of purchase and purchaser (i.e. insurance; private)
clinical evaluation by patient’s PCP addressing ambulatory ability
prognosis (in LOMN form)
Wheelchair evaluation by PT/OT within 6 months for clients 21 and older; Shriners and primary Children’s are affiliates within 3 months for under 21
Patient skills check list for power chair
barriers to transport
use/accessibility of residents have been addressed
repair history of current wheelchair (if applicable)

Denials due to missing documentation

Did you receive a denial code (AUT) for lack of prior authorization?

Please fill out and submit an Appeal Form.

Submitting Claims

Process claims fastest through
the Provider Portal using accurate coding.

Check for coding updates and ensure thorough documentation before submission to avoid delays.

Clinical Edits – Effective April 1, 2026

Claims Mailing Address
Mountain Health Co-Op
PO Box 30311
Salt Lake City, UT 84130

Payer ID: MHC01

Receive Electronic Payments

Payment forms can be completed via the Change Healthcare website.

Whether you’re a new or current user, click “Begin Enrollment” on Change Healthcare’s Payer Enrollment page and follow the prompts.

New Client Signup Step 1 – Connect Center (changehealthcare.com)

If there are any questions, please contact Change Healthcare at 1-800-527-8133, option 1

General Guides

The Claims Editing process is changing Oct. 17, 2024 - what do I need to know?

Effective October 17, 2024, important updates will impact Mountain Health Co-Op’s claims editing process. These changes are part of our ongoing efforts to streamline and improve the accuracy of claims processing.

Key Changes

New Editing Rules: We have introduced updated editing rules that will affect how claims are processed. These rules are designed to ensure compliance with the latest industry standards.
Training and Support: To assist with the transition, we will be able to assist with any questions. We encourage you to familiarize yourself with the new claims editing process.

Actions Required

Click here to view the new claims editing rules
Reach out to our team by emailing [email protected] if you have questions or need assistance.

How do I start using Mountain Health Co-Op’s new Payer ID?

Direct connection to Optum users:
Follow these steps to enable the new Payer ID, submit electronic claims, verify eligibility, and set up ERA & EFT:

For information on connected payer lists, visit: Payer Lists | Change Healthcare.

Existing Optum Users:

- Information sent by Optum: (Link to information below)

UPDATE: New Electronic Claims Connections Available

Mountain Health CO-OP is now available for claim submission.

Original notice:

Effective September 1, 2024, Optum will have new electronic claims connections available:

Payer Name: Mountain Health CO-OP

Institutional CPID: 7565

Professional CPID: 2499

Payer-assigned Payer ID: MHC01

Payer Enrollment Required: No

Secondary Claims Accepted: Yes

Payer Location: Montana, Wyoming, Utah

Claims Fee: NA

Effective August 15, 2024, discontinue using CPIDs 4779 and 5920, linked to University of Utah payer ID SX155, for Mountain Health CO-OP claims. Please hold claims until CPID’s 2499, 7565 are available on September 1, 2024.

Action Required:

Effective August 15, 2024, discontinue using CPIDs 4779 and 5920, linked to University of Utah payer ID SX155, for Mountain Health CO-OP claims.

Add Mountain Health CO-OP to your system to begin using the new payer connection under CPIDs 2499 and 7565, payer ID MHC01 on September 1, 2024.

When a payer requires enrollment, forms must be submitted and approved to begin submitting transactions.

New Optum users:

- Use the steps below to set up an account:

Create an Optum Provider Portal Account by clicking this link: Optum Provider Port

In the top right corner of the page, click ‘Sign In,’ then ‘Create Account’ and follow the steps to register.

If you have any issues enrolling, please contact Optum at 1-800-527-8133 (7 a.m.-5:30 p.m. CT, Monday-Friday).

How do I receive electronic payments?

Please complete a new ETF enrollment form. You can find payment forms by logging into Optum’s platform or by contacting your trading partner who handles your clearinghouse activities

Client Signup Step 1 – Connect Center (changehealthcare.com)

Whether you’re a new or current user, click “Begin Enrollment” on Change Healthcare’s Payer Enrollment page and follow the prompts.

If you encounter any issues, contact Optum at 1-800-527-8133.

EFT Form

What if I use a trading partner for submitting electronic claims, verifying eligibility, and receiving ERA & EFTs?

If you use a trading partner (EHR, PC, RMC), contact your trading partner to enable the use of Mountain Health Co-Op’s new Payer ID: MHC01.

For more details on connected payer lists, visit Payer Lists | Change Healthcare, or check the FAQ link provided: Change Healthcare Payer Enrollment FAQ.

Notice: Billing Respective Code Sets In accordance with the International Classification of Diseases, 10th Revision (ICD-10) and Current Procedural Terminology (CPT) Guidelines for Coding and Reporting, Mountain Health Co-Op will begin to deny claims on April 1st, 2022, when CPT and ICD do not cross match in the respective code set being billed. For accurate reporting of ICD-10/CPT, the documentation should describe the patient’s condition, services as well as symptoms, problems, and reasons for the encounter. Coding to the highest level of specificity is required when supported by the medical record and to support medical necessity.

For assistance: 800-299-6080

AMA Guide for No Surprises Act Disputes

Appeal Form

Behavioral Health, Substance Treatment, Skilled Nursing & Residential Care Authorization Form

CMS 1500 Claim Form

Submit this completed form by fax to 800-781-6260 (preferred) or by mail to Mountain Health Co-Op, PO Box 30311,Salt Lake City, UT 84130.

Consent Form

Organization Credentialing Application

Formulary Exception Request Form

To request a drug formulary not listed on MHC Formulary List. To view formulary list and complete pharmacy details View Pharmacy Page.

Home Health Care Request Form

Fax this completed form to 559-243-7012.

Hospice Care Request Form

Practice/Provider Update Form

Use this form to update provider information, add or change a practice location, or adjust billing information.

MRI Criteria Guidelines

No Surprises Act Dispute Form

Non-Formulary Drug Coverage Policy

To view formulary list and complete pharmacy details View Pharmacy Page.

Open Negotiation Notice Instructions (Zelis)

The Open Negotiation Notice must be submitted to [email protected].

Out of Network Waiver Form

Use this form to request out-of-network care.

Prior Authorization Form PDF Version

The best way to submit prior authorization requests is through the Provider Portal.

Prior Authorization Form: Medical Pharmacy

For Specialty Drug Requests. Downloadable PDF Version suitable for faxing. For more details and to view online pharmacy prior authorization version View Pharmacy Page.

Add New Provider Form

Use this form to add a new provider to your already contracted group.

Provider Manual

Our Provider Manual is your definitive guide to working with the Co-Op.

Remove a Provider: Term Request Form

Use this form to remove a single provider that has left the group. For existing group contract questions, please contact [email protected].

Receiving Funds & Setting up EFT

We must have a W-9 on file before we can make any payments to you. If we do not have a direct deposit set up for your group, we will send a paper check.

Retail Drugs Prior Authorization & Exception Forms

Coverage Policies

Services Requiring Prior Authorization

This document is intended only to provide information related to which CPT/HCPCs codes require prior authorization. It does not indicate/list codes which may be excluded from coverage or not covered for other reasons. In addition, inclusion on this list indicates, if covered the code would require prior authorization for coverage.

Skilled Nursing Facility & Acute Rehab Request Form

Authorization Request for SNF, Acute Rehab and LTAC

UB04 Claim Form

Submit this completed form by fax to 800-781-6260 (preferred) or by mail to Mountain Health Co-Op, PO Box 30311,Salt Lake City, UT 84130.

Utilization Mgmt. Medical Policies

We would be happy to provide you with a copy of the criteria we use to make utilization management decisions. Contact the UM team for more info: 833-412-4144. You may also email your request for criteria to [email protected]

Zelis Bill Review for Claim Appeal Form

Zelis Claim Appeal Submittal Form Bill Review Complete all information requested below and fax or email with a copy of complete medical records, itemized bills and a copy of the HCFA-1500 or UB-04 to (908) 658-3511 or [email protected].

Can’t find what you’re looking for?

Try a name search or contact us

Join our Provider Network

Being a Co-Op Provider
As a non-profit, member-owned health insurance CO-OP, we are dedicated to ensuring access to quality cost-effective health insurance for our communities.

We offer an array of benefit plans that will fit your patient’s individual needs.

We believe doctors and hospitals should be fairly compensated for the work they perform.

Questions?
[email protected]

Complete form to receive contract documents.

Shared Decision Making Aids

Coding Updates for Providers

Coding changes happen all the time. Join, or watch, our scheduled live webinars and read our quarterly Provider E-Newsletter to stay updated.

Learn now

Evaluation and Management CPT Updates

January 2024

Sequela & Complication Coding

Fall 2023 Webinar

Wellness Coding

Summer 2023 Webinar

CMS Information

Provider Newsletters

Spring 2024

Trying to discern member information when you have a busy front office can be frustrating. To recognize our members more easily read more.

Year End Message - Winter 2023

As we close the door on yet another year of successful partnership, and our shared goal of improving healthcare outcomes and ensuring that every individual receives the care they deserve, I wanted to thank you for working with Mountain Health CO-OP. It’s true, we are smaller than most, but our roots run deep, and our heart is always where it needs to be, with our members.

Summer 2023

Details about our latest updates, telehealth, and Medicaid unwinding.

Spring 2023

Details about important updates.

Winter 2022

Now that 2022 is behind us, this is an excellent time to review patient records to ensure everyone is current with their annual preventive visits for 2023.

Fall 2022

We’re pleased to announce the successful launch of the new, secure Mountain Heal CO-OP Provider Portal.

Summer 2022

The Federal No Surprises Act went into effect January 1, 2022, bringing new requirements for health plans and providers.

Spring 2022

In recent years, suicide rates have continued to rise. This topic needs to be continually talked about to bring more education around suicide prevention.

Machine Readable Files

2025 ID Plans

2025 ID Providers: https://rmm.mhc.coop/plans_providers/38128_ID_Provider_2025.json

2025 ID Formulary: https://cbg.adaptiverx.com/web/json?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B681DE892A5D56965B4

WYOMING

2025 WY Plans: https://rmm.mhc.coop/plans_providers/38576_WY_Plans_2025.json

2025 WY Providers: https://rmm.mhc.coop/plans_providers/38576_WY_provider_2025.json

2025 WY Formulary: https://cbg.adaptiverx.com/web/json?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B681132E9A3F5959663

2024 WY Plans: https://doc.uhealthplan.utah.edu/individual/json/38576_WY_Plans_2024.json

2024 WY Providers: https://uhealthplan.utah.edu/individual/json/38576_WY_provider.json

2024 WY Formulary: https://cbg.adaptiverx.com/web/json?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B68765C9638CD4FA731

Tools & Resources

Forms & Docs

Tools & Resources

Forms & Docs

Forms & Docs

Tools & Resources

Forms & Docs

Tools & Resources

Search site...

or Get Specific...

Search site...

or Get Specific...

Idaho

Montana

Wyoming

Idaho

Montana

Wyoming

Your Coverage

Managing Your Plan

Your Coverage

Managing Your Plan

Login

Search site...

or Get Specific...

for managing

for managing

for managing

Search all Provider Forms & Documents

AMA Guide for No Surprises Act Disputes

Appeal Form

Behavioral Health, Substance Treatment, Skilled Nursing & Residential Care Authorization Form

CMS 1500 Claim Form

Submit this completed form by fax to 800-781-6260 (preferred) or by mail to Mountain Health Co-Op, PO Box 30311,Salt Lake City, UT 84130.

Consent Form

Organization Credentialing Application

Formulary Exception Request Form

To request a drug formulary not listed on MHC Formulary List. To view formulary list and complete pharmacy details View Pharmacy Page.

Home Health Care Request Form

Fax this completed form to 559-243-7012.

Hospice Care Request Form

Practice/Provider Update Form

Use this form to update provider information, add or change a practice location, or adjust billing information.

MRI Criteria Guidelines

No Surprises Act Dispute Form

Non-Formulary Drug Coverage Policy

To view formulary list and complete pharmacy details View Pharmacy Page.

Open Negotiation Notice Instructions (Zelis)

The Open Negotiation Notice must be submitted to [email protected].

Out of Network Waiver Form

Use this form to request out-of-network care.

Prior Authorization Form PDF Version

The best way to submit prior authorization requests is through the Provider Portal.

Prior Authorization Form: Medical Pharmacy

For Specialty Drug Requests. Downloadable PDF Version suitable for faxing. For more details and to view online pharmacy prior authorization version View Pharmacy Page.

Add New Provider Form

Use this form to add a new provider to your already contracted group.

Provider Manual

Our Provider Manual is your definitive guide to working with the Co-Op.

Remove a Provider: Term Request Form

Use this form to remove a single provider that has left the group. For existing group contract questions, please contact [email protected].

Receiving Funds & Setting up EFT

We must have a W-9 on file before we can make any payments to you. If we do not have a direct deposit set up for your group, we will send a paper check.

Retail Drugs Prior Authorization & Exception Forms

Coverage Policies

Services Requiring Prior Authorization

Skilled Nursing Facility & Acute Rehab Request Form

Authorization Request for SNF, Acute Rehab and LTAC

UB04 Claim Form

Submit this completed form by fax to 800-781-6260 (preferred) or by mail to Mountain Health Co-Op, PO Box 30311,Salt Lake City, UT 84130.

Utilization Mgmt. Medical Policies

We would be happy to provide you with a copy of the criteria we use to make utilization management decisions. Contact the UM team for more info: 833-412-4144. You may also email your request for criteria to [email protected]

Zelis Bill Review for Claim Appeal Form

Zelis Claim Appeal Submittal Form Bill Review Complete all information requested below and fax or email with a copy of complete medical records, itemized bills and a copy of the HCFA-1500 or UB-04 to (908) 658-3511 or [email protected].

Spring 2024

Year End Message - Winter 2023

Summer 2023

Spring 2023

Winter 2022

Fall 2022