Change Healthcare is currently experiencing difficulties. If you are a provider who receives payments from Mountain Health CO-OP through Change Healthcare, please sign up for electronic payments through our clearinghouse, UHIN. Get started.
Questions for UHIN? Email [email protected] or call 877-693-3071.
If you have been affected by the cyber attack and are interested in short-term relief through Mountain Health CO-OP, email us at [email protected] or call (406) 447-5782.
Prior Authorizations
Use the Provider Portal to request and review prior authorizations and all other patient details.
Online submission is preferred method (Previously labeled: Medical Electronic Request Form)
Appeals
For questions about appeals: 1-844-262-1560
Claims
For assistance: 877-814-9909
[email protected]
All Provider Forms & Documents
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AMA Guide for No Surprises Act Disputes
Appeal Form
Behavioral Health Provider Policies
Residential Treatment Center (RTC) Requirements Policy
Behavioral Health/Substance Request Form
Claims Submission
Claims should be submitted through our plan administrator’s clearinghouse, the Utah Health Information Network (UHIN). More details: http://www.uhin.org/
Consent Form
Formulary Exception Request Form
Suitable for faxing
Home Health Care Request Form
For a better experience, complete your request here Or you may fax your request: 801-213-1358. Please include this document at the front of your submission.
Hospice Care Request Form
Location Add/Change Form
Use this form to add a location, change location, and change billing information.
Medical Documentation Submission Form
Use this form, along with missing documentation, for MDOC claim denials.
Medical Drugs Prior Authorization List
Medical Provider Policy
The University of Utah Health Plans ® Medical Policy Manual and Coding/Reimbursement Policy Manual contain policies approved by U of U Health Plans.
MRI Criteria Guidelines
No Surprises Act Dispute Form
Non-Formulary Drug Coverage Policy
Open Negotiation Notice Instructions (submit to [email protected] only)
The Open Negotiation Notice must be submitted to [email protected] and not to University of Utah Health Plans (UUHP).
Prior Authorization E-Form
Medical Electronic Request Form (PREFERRED METHOD) for Prior Authorization
Prior Authorization Form PDF Version
(Suitable For Faxing)
Prior Authorization Form: 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.
Provider Add Form
Use this form to add a new provider to your already contracted group.
Provider Manual
This manual is where you can look for policies and procedures.
Provider Term Request Form
Use this form to remove a provider that has left the group.
Receiving Funds & Setting up EFT
We must have a W-9 on file before we can make any payments to you. You can fax your W-9 form to 801-281-6121. 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
Retail Pharmacy Appeal Form
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
Submitting Additional Documentation
For submitting additional documentation, please use the Medical Documentation Submission Form.
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: 855-447-2900 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.
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
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.
Fall 2021
Mountain Health CO-OP, in collaboration with University of Utah Health Plans (UUHP), has been in the process of creating a new secure portal to replace the current LINK Provider Portal.
Summer 2021
The CO-OP is excited to share our new website. This website has been built to create an
easier user experience for our members, providers, and brokers. The website is easier to navigate, with updated information, a user-friendly.
Winter 2021
According to the July 16, 2020 NCQA blog, “Kidney disease affects 37 million American adults, but 90% are unaware they even have it.”
Provider Contacts
Idaho
Greg Sonnenberg
Vice President
Lindsey Shelton
Provider Network Specialist
855-447-2900 – Option 6
Montana
Leah Martin
Assistant Vice President
Jill Martin
Provider Network Specialist
Taetumn Bailey
Provider Network Specialist
855-447-2900 – Option 6
Wyoming
Morris McGaugh
Director
Lindsey Shelton
Provider Network Specialist
855-447-2900 – Option 6
General
Patient eligibility and benefits:
1-844-262-1560
Prior authorizations for medical services:
1-801-587-2851
855‐885‐7695
801-213-2132
Machine Readable Files
WY Providers: https://uhealthplan.utah.edu/individual/json/38576_WY_provider.json
WY Formulary: https://cbg.adaptiverx.com/web/json?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B684B8B05E60D7B96C5
WY 2024 Formulary: https://cbg.adaptiverx.com/
WY 2021 Plans: https://uhealthplan.utah.edu/individual/json/38576_WY_Plans_2021.json
WY 2022 Plans: https://uhealthplan.utah.edu/individual/json/38576_WY_Plans_2022.json
WY 2023 Plans: https://uhealthplan.utah.edu/individual/json/38576_WY_Plans_2023.json
WY 2024 Plans: https://doc.uhealthplan.utah.
ID Providers: https://uhealthplan.utah.edu/individual/json/38128_ID_provider.json
ID 2021 Plans: https://uhealthplan.utah.edu/individual/json/38128_ID_Plans_2021.json
ID 2022 Plans: https://uhealthplan.utah.edu/individual/json/38128_ID_Plans_2022.json
ID 2023 Plans: https://uhealthplan.utah.edu/individual/json/38128_ID_Plans_2023.json
MT Providers: https://uhealthplan.utah.edu/individual/json/32225_MT_provider.json
MT 2023 Formulary: https://cbg.adaptiverx.com/web/json?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B683776EC592BD4A9DE
MT 2024 Formulary: https://cbg.adaptiverx.com/
MT 2021 Plans: https://uhealthplan.utah.edu/individual/json/32225_MT_Plans_2021.json
MT 2022 Plans: https://uhealthplan.utah.edu/individual/json/32225_MT_Plans_2022json
MT 2023 Plans: https://uhealthplan.utah.edu/individual/json/32225_MT_Plans_2023.json
MT 2024 Plans: https://doc.uhealthplan.utah.