University of Utah Health Plans Fraud and Abuse Reporting Form

Please Note: Only sections one and eight are required. However, it is very helpful to have all sections filled out so we can research the issue(s).

If you need help filling out this form, call us at 801-587-6480 or 1-888-271-5870. (Si necesita ayuda para llenar o completar este formulario, llamenos al 801-587-6480 o 1-888-271-5870). If you are deaf or hard of hearing, you can call Utah Relay Services at 711 or 1-800- 346-4128. Si habla español, puede llamar a Spanish Relay Utah al 1-888-346-3162. These are free public telephone relay services or TTY/TDD. Estos son servicios gratuitos de retransmisión telefónica pública o TTY / TDD.

Member Information

Are you the provider, the member, or a UUHP Customer Service Representative?

Provider
Member
UUHP Customer Service Representative

Your information (please note, you do not need to provide your name and phone number but it helps us to know who to call if we have additional questions):

Your Name:

Your Phone Number:

Name of member involved if applicable:

Member Name:

Member ID Number:

Member Street Address:

Member 2nd Street Address:

Member City:

Member State:

Member Zip Code:

Member Phone Number:

Provider Information

Name of Provider Involved:

Provider Street Address:

Provider City:

Provider State:

Provider Zip Code:

Provider Phone Number:

Provider Specialty:

Insurance Product

Healthy Advantage Healthy Advantage Plus Healthy Premier Healthy Preferred University Health Care Plus

Fraud Information

Date(s) of medical service(s) related to this report if applicable:

Medical claim number(s) if applicable:

Please describe the suspected fraud and abuse:

Upload File

Select file #1: Select file #2: Select file #3: Select file #4: Select file #5:

You can fax the information to the Fraud Team at the fax # 801-587-9985.

You may mail the information to:
Fraud Team
6053 Fashion Square Dr., Suite 110
Murray, UT 84107

  

Please note: If you have any additional information, you may mail it to: UUHP, Attn: Fraud and Abuse Officer, 6053 Fashion Square Drive, Suite 110, Murray, UT 84107. You may also contact the Fraud and Abuse officer at 1-888-271-5870.