The Provider Appeal process applies to the following services:

• Utilization management adverse determinations (e.g., claims for services considered not medically necessary, experimental/ investigational, cosmetic);
• Adverse determinations for Pre-service/authorization/referral requirements;
• Adverse Benefit/eligibility determinations (e.g., claims for noncovered services);

For more information, please refer to the Provider Manual.

First Level Appeal Provider Appeal
Utilization management, preservice, and benefit determinations will be processed through the Formal Appeal process. To initiate a First-level Appeal, the provider must submit in writing the nature of the appeal and justification to overturn the initial determination. Copies of pertinent medical records and other forms of documentation that will aid in Mountain Health Co-Op’s review should be included with the submission. The appeal must be submitted within the timeline described below. Each appeal will be determined within the guidelines below.

Second-Level Provider Appeal
Providers may proceed with a second-level appeal if they disagree with the Co-Op’s determination from the first-level appeal. The Second level appeal must be in writing, including why the provider disagrees with the decision and provides new materials to support their position. The second-level appeal must be submitted within 30 calendar days of the first-level determination. Additional medical records and other forms of documentation not previously submitted should accompany the second-level appeal. If no new documentation is supplied, the dispute will be dismissed.

Additional Appeal Options
In rare instances, upon mutual agreement, MHC and Providers may enter Arbitration or Mediation in an attempt to resolve outstanding items. Providers must initiate this additional appeal option in writing.

Dispute or Appeal Level	Time Frame for Submission from the Date of Adverse Determination	MHC/TPA Response Timeframe from the Date of Receipt	Contact
Provider Dispute: related to claims edits, pricing	Within 180 calendar days of the adverse determination	30 calendar days	Phone: 800-299-6080 Fax: 1-800-781-6260 Mail: Wipro HealthPlan Services PO Box 30311 Salt Lake City, UT 84130
First Level Provider Appeal: related to denials for medical necessity, investigational, contract exclusions	For Preservice Denials: Within 90 calendar days of the initial adverse determination For Post-Service Denials: Within 180 days of the initial adverse determination	Preservice: 30 calendar days Post Service: 60 Days Expedited: 72hrs	Phone: 800-299-6080 Fax: 1-800-781-6260 Mail: Wipro HealthPlan Services PO Box 30311 Salt Lake City, UT 84130
Second Level Provider Appeal: related to denials for medical necessity, investigational, contract exclusions	Within 30 calendar days of the decision of the first-level determination	30 Calendar Days Post Service: 60 Days Expedited: 72 Hours	Phone: 800-299-6080 Fax: 1-800-781-6260 Mail: Wipro HealthPlan Services PO Box 30311 Salt Lake City, UT 84130