Neurobehavioral HOME Customer Appeal Form

Please Note: Use this form if you are contacting us about a denied claim (e.g. timely filing, nonparticipating provider) or a denied or reduced service. For other complaints, please use the Customer Complaint Form.

You can also file an Oral appeal by calling HOME member services at 801-585-1960 or 1-800-824-2070. (También puede presentar una apelación oral llamando a los servicios para miembros de HOME al 801-585-1960 o al 1-800-824-2070.)

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.

An appeal must be filed within 60 days from the date of Notice of Adverse Benefit Determination (denied or reduced services). If your appeal is about a service you get that is ending or being reduced, do you want to get the service during the appeal review? You will need to file your appeal within 10 days from the Adverse Determination or the intended date of HOME's planned action.

HOME will complete your Appeal within 30 days from the day it was filed. If we need more time (up to 14 calendar days), we will notify you

You can choose to keep getting service(s) during your appeal but you might have to pay for them if we do not decide in your favor.
I give my verbal consent for this request to be considered a written appeal. I agree this information is correct and complete to the best of my knowledge.
Member Information
Are you the provider, the member, or a UUHP Customer Service Representative?
Provider Information
Appeal Information
Is this an appeal for:
If your appeal is for a denied or reduced service (e.g., benefits are being reduced for home health care), do you have an urgent health need or is your life in danger? Would you like to ask for a quick review? (This does not apply to payment disputes or post service reviews.)

If we agree you need a quick review, we will make a decision on your appeal with 72 hours.

Do you want to appear in person to present your appeal? If yes, we'll send you a notice of the date, time, and location to present your appeal.
You have the right to submit comments, documents or information for the appeal. Do you have more information you would like to send for the appeal? You can attach records below.
   
Upload File
You can fax the information to the Appeals Team at the fax # 801-587-9985.
You may mail the information to:
Appeals Team
6053 Fashion Square Drive, Suite 110
Murray, UT 84107