Provider Resources
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
The best way to request prior authorization is by submitting a completed Prior Authorization form through the MyCare portal.
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.
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)
Did you receive a denial code (252 and/or M127) for missing medical documentation (MDOC)?
Please only use the Retroactive Prior Authorization Form in response to 252 and/or M127 denial codes.
Pharmacy Prior Auth
Formulary
Nursing & Care Requests
Behavorial Requests
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.
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 us at 1-833-412-4144.
The best way to manage appeals is through the relevant online portal at mycarehc.com/provider.
However, you may also submit a PDF version by selecting from the forms list.
Fax
800-781-6260
—
For Expedited Processing
HealthComp UM Department
PO Box 45018
Fresno, CA 93718-5018
For Regular Processing
Mountain Health Co-Op
PO Box 30311
Salt Lake City, UT 84130
Oral requests for appeals can be made by calling 833-412-4144.
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: (need better instructions)
Phone
Fax
Email
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)
Did you receive a denial code (252 and/or M127) for missing medical documentation (MDOC)?
Use this form to submit missing documentation.
Please only use this form in response to 252 and/or M127 denial codes.
Check for coding updates and ensure thorough documentation before submission to avoid delays.
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
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.
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:
- Sign up for ERA and EFT using this link: Client Signup Step 1 – Connect Center (changehealthcare.com)
- 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).
Please complete a new ERA enrollment form. You can find ERA 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.
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.
For assistance: 800-299-6080
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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
- Anticoagulation Choice
- Cardiovascular Prevention Choice
- Chest Pain Choice
- Depression Medication Choice
- Diabetes Medication Choice
- Graves Disease Treatment Choice
- Head CT Choice
- Osteoporosis Choice
- Percutaneous Coronary Intervention Choice
- Rheumatoid Arthritis Choice
- Smoking Cessation Around the Time of Surgery
- Statin Choice
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.
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.
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.
Get in Touch
Provider Contacts
Montana
Leah Martin
Assistant Vice President
Jill Martin
Provider Network Specialist
Taetumn Bailey
Provider Network Specialist
800-299-6080
General
Patient eligibility and benefits:
800-299-6080
Prior authorizations for medical services:
833-412-4144
855‐885‐7695
559-243-7012
559-243-7012
Machine Readable Files
WYOMING
WY 2024 Formulary: https://cbg.adaptiverx.com/
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
2025 WY Plans: https://rmm.mhc.coop/plans_providers/38576_WY_Plans_2025.json
WY 2024 Plans: https://doc.uhealthplan.utah.
WY 2024 Providers: https://uhealthplan.utah.edu/individual/json/38576_WY_provider.json
IDAHO
ID Providers: https://rmm.mhc.coop/plans_providers/38128_ID_Provider_2025.json
2025 ID Formulary: https://cbg.adaptiverx.com/
MONTANA
2025 MT Providers: https://rmm.mhc.coop/plans_providers/32225_MT_provider_2025.json
2025 MT Formulary: https://cbg.adaptiverx.com/web/json?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B68E83006C9BA3157B0
2025 MT Plans: https://rmm.mhc.coop/plans_providers/32225_MT_Plans_2025.json
MT 2024 Formulary: https://cbg.adaptiverx.com/
MT 2024 Plans: https://doc.uhealthplan.utah.