A claim is a request to an insurance company for payment of health care services.  Usually, providers file claims with us on your behalf.  If you received services from an out-of-network provider, and if that provider does not submit a claim to us, you can file the claim directly.  There are time limits to how long you have to submit claims, with details on the limit below.  You can also check your specific plan's claims filing time limit information to determine the time limit for submitting your claim.

Time limit: 365 days

To file a claim, you must:

• Complete the MHC Claim Form completely
• Attach an itemized bill from the provider for the covered service
• Make a copy for your records
• Submit your claim to the address below:
  Mountain Health CO-OP
  Claims Administrator
  P.O. Box 30311
  Salt Lake City, UT 84130
• Alternatively, you can fax your completed form and supporting documentation to 1-800-781-6260

To Expedite your Claim Request

• Make sure the bills identify the patient.
• All bills should show the date of treatment, description of service, and amount of charges.
• Procedure Codes and Diagnosis codes must be included or claim form will be returned.
• All statements should have Member identification number listed.

Forms

• Medical Claim Form
• Prescription Claim Form
• Claim Denial: Incapacitation Review