In the various workshops, presentations, and surveys we conduct throughout each year, appeals is one topic that always raises questions. Here are some of the most common appeal issues we address, along with trends we see in submitted appeals.

CORRECTED CLAIM VS APPEAL

The examples below clarify which denials should be resolved with a corrected claim and which require an appeal. These examples are not comprehensive.

DENIALS BEST ADDRESSED THROUGH THE CORRECTED CLAIM PROCESS

If your denial occurred due to missing, incorrect, or incomplete information, or if you identify an error after submission, please submit a corrected claim.

Information That Can Be Corrected on a Claim

• Incorrect patient information (e.g., demographics or insurance information)
• Incorrectly reported procedure or diagnosis code(s)
• Missing coding information (e.g., modifiers or units)
• Missing medical documentation (e.g., medical records supporting necessity, sterilization forms)
• Missing Coordination of Benefits (COB) information (e.g., primary EOP, PIP exhaust letter)

Duplicate Claims

If the claim was denied as a duplicate:

• Ensure the original claim has finished processing before resubmitting a corrected claim.
• Ensure you are applying the correct claim number to your corrected claim. If you need help identifying it, contact Customer Service for the member's benefit plan.
  Note: If you do not include the processed claim number on the corrected claim, the corrected claim will be denied as a duplicate.

DENIALS BEST ADDRESSED THROUGH THE APPEALS PROCESS

• Medical Necessity Denials – Submit additional medical records, notes, and documentation supporting the service.
• Authorization Denials – If prior authorization was obtained, include the authorization number and supporting correspondence.
• Experimental/Investigational Denials – Provide clinical evidence or peer‑reviewed literature supporting the treatment.
• Coverage Termination Denials – If you have proof of active coverage, submit that documentation.
• Denial Error – If you believe a denial was incorrectly applied, submit an appeal with evidence supporting reversal.

Appeal Submission

Health Choice Utah offers one level of internal appeal. Submit one complete, thorough appeal with a detailed appeal statement and all supporting documentation to maximize your chance of overturning the denial. 

REQUESTS FOR MAGNETIC RESONANCE IMAGING (MRI) SERVICES

Prior authorization is required for MRIs. When appealing an MRI denial, you must include:

• Office visit notes
• Progress notes
• Physical exam details
• Abnormal findings
• Duration of symptoms
• Documentation of failed conservative treatments

Note: Medical necessity cannot be determined from the MRI report alone.

MEDICAID OUTPATIENT HOSPITAL ADJUSTMENT FACTOR

Health Choice Utah Medicaid, in coordination with Utah Medicaid and CMS, recently clarified the outpatient adjustment factor ("decoupler") used with specific Outpatient Prospective Payment System (OPPS) status indicators.

MEDICAID RATE DISPUTES

Participating providers receive an established payment amount for each rendered service.

Unless otherwise specified in your contract, payment is determined by the state fee schedule, available on the PRISM Coverage and Reimbursement Lookup Tool.