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Member Appeals

Most member issues can be resolved informally through Member Services by calling 800-538-5038. If a member is not satisfied after attempting to resolve the problem with Member Services, they may choose to: 

1. Initiate a formal appeal themselves (see information at https://selecthealth.org/member-care/member-resources​
2. Authorize someone else (such as a provider) to do so on their behalf 

A member can designate their provider to represent them through the formal appeals process without having to provide a written authorization to do so. A written authorization is required if a member wants to designate anyone other than a provider (for example, a spouse, family member, or an attorney).

Filing requirements for making a formal appeal differ based on the type of plan as follows:

  • For Commercial plans: Formal appeals must be filed within 180 days from the date of denial notification.
  • For Government plans
  • SelectHealth Advantage (Medicare) plans: Formal appeals must be filed within 60 days of the Adverse Benefit Determination. NOTE: Contract providers do not have appeal rights under the member appeals process. Contract provider disputes involving plan payment denials are reviewed through the Provider Appeal​ dispute resolution process between the provider and the plan.
  • SelectHealth Community Care (Medicaid) plans: Formal appeals must be filed within 60 days of the Adverse Benefit Determination.
  • CHIP: Formal appeals must be filed within 90 days of the Adverse Benefit Determination.
  • ​Federal Employee Health Benefits program: Formal appeals must be filed within six months from the date of denial notification.
 
The following details the overall appeals process for providers filing claims on behalf of a members. 

The Appeals Process


Begin the process of filing a formal appeal of any Adverse Benefit Determinization on behalf of an enrollee and with the enrollee’s consent by completing and submitting the Provider Appeal Form​ online. 

Definitions

  • Adverse Benefit Determination. The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part, of payment for a service; the failure to provide services in a timely manner, as defined by the state of Utah; the failure of SelectHealth to act within the timeframes provided in this section; or for a resident of a rural area with only one managed care organization, the denial of a Medicaid enrollee's request to exercise his or her rights, under 42 CFR § 438.52 (b)(2)(ii), to obtain services from a nonparticipating provider.
  • Appeal. Review by SelectHealth of an Adverse Benefit Determination.
  • Urgent Preservice Claim. Any preservice claim that, if subject to the normal timeframes for determination, could seriously jeopardize the enrollee’s life, health or ability to regain maximum function or would subject the enrollee to severe pain that could not be adequately managed without the requested service.

The full appeals process is outlined below.

Appeals on Behalf of Members: Process Diagram and Notes

(Roles indicated in parentheses and green type)​

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