Welcome to Our Family!
Thank you for choosing Health Choice Utah to provide your healthcare. We look forward to serving you and your family.
Member Services Department
The Member Services Department can help members with any questions they may have about the health plan.
If you have a question about your health, Member Services can help you, call us at 1-877-358-8797. Our Member Services Department is open (Monday – Friday, 6 a.m. – 6 p.m., except holidays)
The Member Services Department can help you with many questions like these:
- How do I change my doctor?
- What is a covered service?
- What pharmacies can I use?
- Do I currently have coverage?
- What do I do if I move from my service area?
- Can I change to a different plan?
You are responsible for arranging your own transportation to and from your medical appointments. You must try to use your own car, take the bus, or have a family member or friend give you a ride. If you cannot drive yourself, get a ride or if you cannot pay for a ride, you can ask for a Utah Transit Authority (UTA) bus pass by calling your Medicaid Eligibility Worker.
If there is a medical reason you can’t use the bus, you may qualify for services through UTA FlexTrans or PickMeUp Medical Transport. To apply for this service call the Medicaid Information Line at 801-538-6155 or 1-800-662-9651 and ask for the Transportation Unit.
Important Information for Members
Please see the following sections for important information for our members:
Quality Management Performance Measures tell Health Choice Utah how well we are achieving goals set by Medicaid in the areas of preventive health services such as well care visits, dental visits, breast cancer screenings and many more. Medicaid uses Healthcare Effectiveness Data and Information Set (HEDIS®) 2007 specifications to collect and report results of these measures. Developed and maintained by the National Committee for Quality Assurance (NCQA), HEDIS is the most widely used set of performance measures in the managed care industry.
Health Choice Utah continuously checks our Quality Management Performance Measures to identify areas for improvement and apply interventions to help more of our members use preventive services so they can stay healthy!
There may be a time when you are so sick that you cannot make a decision about your own healthcare. You, or a representative chosen by you, have the right to make decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment within the requirements of Federal and State law with respect to advance directives [42 CFR 438.6].
An Advance Directive is a paper that protects your right to refuse healthcare you do not want. It may also tell people about care that you do want.
There are four types of Advance Directives:
Living Will (End of life care)
A Living Will is a piece of paper that tells doctors what types of services you do or do not want if you become very sick and near death and may not be able to make healthcare decisions or give consent for yourself. For example, in your Living Will you might tell doctors if you want to be kept alive with machines or fed through tubes if you cannot eat or drink on your own.
Medical Power of Attorney
A Medical Power of Attorney is a paper that lets you choose a person to make decisions about your healthcare when you cannot do it yourself.
Mental Healthcare Power of Attorney
A Mental Healthcare Power of Attorney names a person to make decisions about your mental healthcare if it is found that you cannot.
Pre-Hospital Medical Directive (Do Not Resuscitate)
A Pre-Hospital Medical Care Directive tells providers if you do not want certain lifesaving emergency care that you would get outside a hospital or in a hospital emergency room. You must complete a special orange form. You can get a free copy of this form by calling the Bureau of Emergency Medical Services at 801-538-6003.
Health Choice Utah respects your right to make decisions about your healthcare and thinks that it is important for you to have one or more of these papers.
You should get help writing your Living Will and Medical Power of Attorney. Ask your doctor for help if you are not sure who to call.
Making Your Advance Directives Legal
For both a Living Will and a Medical Power of Attorney, you must choose someone who will make decisions about your healthcare if you cannot. This person can be a family member or a close friend and is called your agent.
To make an Advance Directive legal, you must:
Sign and date it in front of another person, who also signs it. This person cannot:
- Be related to you by blood, marriage or adoption;
- Have a right to receive any of your personal and private property upon death;
- Be appointed as your agent; or
- Be your healthcare provider.
- Sign and date it in front of a Notary Public. The Notary Public cannot be your agent or any person involved with the paying of your healthcare.
If you are too sick to sign your Medical Power of Attorney, you may have another person sign for you.
After you Complete your Advance Directives
- Keep your original signed papers in a safe place.
- Give copies of the signed papers to your doctor(s), hospital, and anyone else who might become involved in your healthcare. Talk to these people about your wishes concerning your healthcare.
- If you want to change your papers after you have signed them, you must complete new papers. You should make sure you give a copy of the new paper to all the people who already had a copy of the old one.
- Be aware that your directives may not be effective in a medical emergency.
Source of Additional Information and Forms
The following organization provides healthcare directive forms and information:
Aging Services Administrative Office
195 North 1950 West Salt Lake City, UT 84116
Phone: (801) 538-3910
Toll free: 1-877-4aging0 or 1-877-424-4640
Fax: (801) 538-4395
Your local Area Aging and Senior Center may also have forms and information.
If you have complaints about your right to make healthcare decisions, you may contact the Health Choice Utah Member Services Department at 1-877-358-8797.
It is very important for you to decide what treatment you do or do not want.
- Give copies of your Living Will and/or Medical Power of Attorney to your doctor, hospital and any other people involved with your healthcare.
- If you change any part of your Living Will or Medical Power of Attorney, you should make sure you give a copy of the new one to all the people who already had a copy of the old one.
As a Health Choice Utah Member, you have the following rights:
- You have the right to be treated with respect and dignity.
- You have the right to privacy and confidentiality concerning your healthcare and your medical records and other member information. All information about your health is private except when the release is allowed by law.
- You have the right to not be discriminated against in the delivery of healthcare services based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.
- You have the right to have services provided in a culturally competent manner with consideration for your ability to read and understand English, your cultural or ethnic background, or if you have visual or hearing limitations. Options include access to a language interpreter, a person who can perform sign language if you have a hearing impairment, and written materials available in Braille for visual impairments, or in different formats, as appropriate. You have the right to know about providers who speak languages other than English.
- You have the right to choose a Primary Care Provider (PCP), within the limits of the Health Choice Utah provider network, and choose other providers as needed from among those affiliated with the network. This also includes the right to refuse care from specified providers.
- You have the right to take part in decision-making about your healthcare and/or have someone, chosen by you, to make choices for you if you are too sick to make healthcare decisions. This includes the right to refuse treatment.
- You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation.
- You have the right to be provided with information so that you can put together advance directives; you, or a representative chosen by you, have the right to make decisions to withhold resuscitative services, or to forgo or withdraw life-sustaining treatment within the requirements of Federal and State law with respect to advance directives [42 CFR 438.6]. This is a plan that tells your healthcare providers what kind of treatment you do or do not want if you become too sick to make you own healthcare decisions.
- You have the right to receive information in a language and format that you understand regarding your rights and responsibilities the amount, duration, and scope of all services and benefits, service providers, services included and excluded as a condition of enrollment, and other information including:
- Provisions for after-hours and emergency healthcare services. You have the right to access emergency healthcare services from contracting or non-contracting providers without prior authorization, consistent with your determination of the need for such services as a prudent layperson.
- Information about available treatment options (including the option of no treatment) or alternative courses of care.
- How to obtain services, including authorization requirements and any special procedures for obtaining mental health and substance abuse services, or referrals for specialty services not furnished by your PCP.
- Procedures for obtaining services outside the geographic service area of Health Choice Utah and how to obtain Medicaid covered services that are not offered or available through the health plan.
- The right to obtain family planning services from an appropriate State Medicaid registered provider.
- A description of how the organization evaluates new technology for inclusion as a covered benefit.
- You have the right to be provided with information regarding grievances, appeals, and requests for hearing.
- You have the right to complain about your managed care organization.
- You have the right to review your medical records in accordance with applicable Federal and State laws; and/or: the right to request annually and at no cost and receive a receive a copy of you medical records as allowed by law (in Title 45 of the Code of Federal Regulations (CFR) 164.524): Your right to access medical records may be denied if the information is:
- Psychotherapy notes.
- Compiled for, or in reasonable anticipation of a civil, criminal or administrative action.
- Protected health information that is subject to the Federal Clinical Laboratory Improvement Amendments of 1988 or exempt pursuant to 42 CFR 493.3(a)(2).
- What this means is that we may use, share or deny sharing health information with you or a legal agency if told to by law which may be in the form of a subpoena, warrant or court order. This may be as a result of a legal matter such as civil, criminal or administrative action.
- You may be denied access to read or receive a copy of the medical record information without a chance for review as allowed by law in 45 CFR Part 164 if:
- The information meets the criteria stated above.
- The provider is a correctional institution or acting under the direction of a correctional institution as defined in 45 CFR 164.501.
- The information is obtained during the course of current research that includes treatment and you agreed to suspend access to the information during the course of research when consenting to participate in the research.
- The information was compiled during a review of quality of care for the purpose of improving the overall provision of care and services.
- The denial of access meets the requirements of the Privacy Act, 5 United States Code (5 U.S. C.) 552a.
- The information was obtained from someone other than a healthcare provider, under the protection of confidentiality, and access would be reasonably likely to reveal the source of the information.
- Except as provided above, you will be informed of the right to seek review if your request to inspect or obtain a copy of the medical record information is denied when:
- A licensed healthcare professional has determined the access requested would reasonably be likely to endanger the life or physical safety of you or another person, or
- The protected health information makes reference to another person and access would reasonably be likely to cause substantial harm to you or another person.
- The health plan must respond within 30 days to your request for a copy of the records. The response may be the copy of the record, or if necessary to deny the request, the written denial must include the basis for the denial and written information about how to seek review of the denial in accordance with 45 CFR Part 164.
- You have the right to amend or correct your medical records as allowed by law in 45 CFR 164.526:
- The health plan may require the request to be in writing.
If the health plan agrees to amend information in the your medical record, in whole or in part, at a minimum, the health plan must:
- Identify the information in the record that is affected, and attach or link to the amended information.
- Inform you, in a timely manner, of the amendment.
- Obtain your agreement to allow the health plan to notify relevant persons with whom the amendment needs to be shared.
- The health plan must make reasonable efforts to inform and provide the amendment, within a reasonable time, to: (i) Persons identified by you as having received protected health information and who need the amendment, and, (ii) Persons, including business associates, that are known to the health plan as having your information affected by the amendment and who have relied on or may in the future rely on the original information which might be to your detriment.
- The health plan may deny the request for the amendment or correction if the information:
- Would not be available for review, as noted above.
- Was not created by the health plan, or one of its providers, unless the individual provide a reasonable basis to believe that the originator of protected health information is no longer available to act on the requested amendment.
- Is not part of the member’s medical record.
- Is already accurate and complete.
- If the request is denied, in whole or in part, the health plan must provide you with a written denial within 60 days that includes:
- The basis for the denial.
- Your right to submit a written statement disagreeing with the denial, and how to file the statement.
- A statement that, if you do not submit a statement of disagreement, you may request that the health plan provide your request for amendment and the denial with any future disclosures of the protected health information that is related to the amendment.
- A description of how you may seek review of the denial in accordance with 45 CFR Part 164.
- You have the right to ask for information about the Health Plan’s Physician Incentive Program and the ways that the health plan pays our providers. You may also ask if stop-loss insurance is required, and you may ask for a summary of the member survey results for the health plan.
- Health plan members are free to exercise his/or her rights and that the exercising of those rights will not adversely affect the treatment of the member by the health plan or its providers.
As a Health Choice Utah Member, you have the following responsibilities:
- To know the name of your assigned doctor known as your Primary Care Provider (PCP).
- To provide, to the extent possible, information needed by the professional staff who is taking care of you (tell your doctor about your health history and/or any medical problems that you have so that you can get the best possible care).
- To follow the advice given by your healthcare provider (doctor), take your medicine as prescribed, talk with your doctor about your medical care, and get the proper PCP approval, as needed.
- To make appointments during office hours whenever possible instead of using urgent care facilities and/or emergency rooms.
- To get to your appointment on time or to call your doctor ahead of time if you cannot make your appointment.
- To bring shot records to every appointment for your children who are 18 years of age or younger.
If you have a concern with any part of your healthcare, or would like to complain about Health Choice Utah please call or write Health Choice Utah at 1-877-358-8797, Monday – Friday, 6:00 am – 6:00 pm and a Member Services representative will assist you.
The problem or concern you are calling about will come under one of two areas: Grievances (Complaints) or Appeals which are explained on the following page.
You can file a grievance or an appeal either over the phone or in writing. To file over the phone, please call us at 1-877-358-8797. To file a grievance in writing, please send your letter to:
Health Choice Utah
Attn: Member Grievances
410 N. 44th Street, Suite 920
Phoenix, AZ 85008
To file an Appeal in writing, please send your letter to:
Health Choice Utah
Attn: Member Appeal
410 N. 44th Street, Suite 920
Phoenix, AZ 85008
Filing a Grievance
A grievance (complaint) is not being satisfied with the way healthcare services were provided to you. Grievances can be about timeliness, appropriateness, access to care, quality of care, staff attitude, rudeness or any other kind of problem you may have had with your healthcare service. A Health Choice Utah Member Services Representative will help you file the grievance and ask you some questions about the concern. Please provide Health Choice Utah with the date the problem happened and any other facts about the problem. Health Choice Utah will look into your grievance. We are here to help you. You will get a letter from us when we receive your grievance and a letter when we are done with the investigation.
If you have received a letter (for example, Notice of Action) regarding a decision to approve or deny a service and you do not understand it, or do not agree with it; please contact the health plan with questions, ask us to re-write the letter, or you may file a grievance. After calling the health plan, if your grievance about the Notice of Action letter is not resolved to your satisfaction, you may complain to the Division of Healthcare Management and Medical Management Unit.
Appeals and Medicaid State Fair Hearing Process
Member Right to Request an Appeal on an Adverse Action
Health Choice Utah may deny services that your doctor asks for or Health Choice Utah may limit or stop care we said you could have. If this happens, you will get a letter from Health Choice Utah called a Notice of Action. The Notice of Action (NOA) will tell you why Health Choice Utah made that decision. We will tell you the law, rule or policy that was used to make their decision and the date that Health Choice Utah made the decision. The Notice of Action will tell you how to ask Health Choice Utah to review the decision. This review is called an Appeal. The Notice of Action will tell you how you can keep getting care during the Appeal process. The Notice of Appeal will also explain that if you lose the Appeal, you will have to pay for the care you got during the Appeals process. Before filing an Appeal, check with your doctor because he or she could have a different plan of care that may be covered.
Requesting an Appeal
You may ask for an Appeal if you get a Notice of Action. You can ask for the Appeal by calling Health Choice Utah Member Services, or by writing a letter to Health Choice Utah. Your Appeal letter has to be sent directly to Health Choice Utah.
You have 90 days from the date of the adverse action to file your Appeal. Health Choice Utah has five (5) work days to send you a letter to let you know that they have received your Appeal. Before you ask Health Choice Utah for an Appeal, and at any time during the Appeal process, you can look at all the paperwork Health Choice Utah used to make the decision. Before Health Choice Utah makes a decision about your Appeal, you can send us more information about your care.
Using a Representative
If you choose to appeal the Notice of Action, you have the right to have help. You can file the Appeal yourself or you can have someone file it for you. If you want someone to help you with your Appeal (like a family member, friend, clergy, or even your doctor) you have to tell the Health Choice Utah Member Appeals Coordinator that you are allowing them to help you.
When Health Choice Utah sends a Notice of Action, we also send a list of agencies that may be able to help you with your Appeal. If you need another list, please call the Health Choice Utah Member Services Department. You cannot have help from someone who will charge you money to represent you.
Your doctor can ask for an Appeal for you. If you want your doctor to ask for your Appeal, you must give your doctor written permission to ask for the Appeal. You or your doctors have 90 days from the date on the Notice of Action to ask Health Choice Utah for the Appeal. If you want to keep getting care during the appeal process, you must follow the rules listed in the section called “Receiving Continued Benefits” on page xx. Send your letter or call:
Health Choice Utah
Attn: Member Appeals
410 N. 44th Street, Suite 920
Phoenix, AZ 85008
Health Choice Utah will have your file reviewed by someone that had nothing to do with your first Notice of Action that denied, limited or stopped care we said you could have. After Health Choice Utah has looked at your file, we will send you a letter telling you our decision. This letter is called a Notice of Appeal Resolution. The Notice of Appeal Resolution will be sent to you within 30 days after getting your Appeal request. (72 hours for an expedited)
Notice of Extension
Health Choice Utah will answer your appeal request as quickly as we can. However, sometimes it is in your best interest that additional time be taken. If Health Choice Utah needs more than 30 days to get all the information needed to fully review to your appeal, we will let you know by sending you a letter. This letter means Health Choice Utah has 14 more days to make a decision. If you need more than 30 days to get all the information you need for your appeal, you can request an extra 14 days to get additional information for your appeal to Health Choice Utah.
You can ask Health Choice Utah to make a decision faster, if waiting 30 days would seriously harm your health, life or your ability to reach, get back, or keep functioning at a maximum level. This is called an Expedited Appeal. Health Choice Utah will let you know if they agree that a fast decision must be made. If Health Choice Utah makes a fast decision, they will try to call you on the telephone. Health Choice Utah will call you in three (3) working days and tell you our Appeal decision. You may still request an Extension of up to 14 days, if it is in your best interest. Health Choice Utah will also send you a letter telling you the decision. This letter is called a Notice of Expedited Appeal Resolution. If Health Choice Utah does not agree that a fast decision has to be made, the Notice of Appeal Resolution will be sent to you in 30 days.
Member’s Right to Request a Medicaid State Fair Hearing on Health Choice Utah’s Appeal Decision
If you do not like the Appeal decision, you can ask for a Medicaid State Fair Hearing. You must ask for the State Fair Hearing in writing. You have 30 days from the date you receive the letter of Notice of Appeal Resolution (or Notice of Expedited Appeal Resolution) to ask for a Medicaid State Fair Hearing. If you want to keep getting care during the hearing process, you must follow the rules listed in the section called Receiving Continued Benefits in the Member Handbook [link to Member Handbook PDF]. Send your letter or call:
Health Choice Utah
Attn: Member Appeals
410 N. 44th Street, Suite 920
Phoenix, AZ 85008
After you ask for a State Fair Hearing you will receive a Notice of Hearing from the DWS. The Notice of Hearing will tell you the law, rule, or policy that will be used at the hearing. The Notice of Hearing will tell you where and when the hearing will be held. DWS will also send you information about the hearing. You can either speak for yourself at the hearing or give permission in writing to a lawyer, relative, friend or anyone to speak for you at the hearing. Before, and during the hearing, you (and the person helping you) can look at all the paperwork that will be used at the hearing. You can bring someone to the hearing that knows about your case. You can also bring information about your case to the hearing.
The Medicaid State Fair Hearing
An Administrative Law Judge will hold the Medicaid State Fair Hearing. The Judge will listen to everything that is said at the hearing and read all the documents used in the hearing. After the hearing, the Judge will send a Recommended Decision to the Utah Department of Workforce Services (DWS). DWS will read the Recommended Decision and agree with it, change it or reject it. DWS will send you a letter telling you the decision. This letter is called a Director’s Decision. The Director’s Decision will tell you if you have won or lost at the hearing. DWS will tell you why it made the decision. DWS will also tell you if you have more appeal rights. DWS will send the Director’s Decision about 90 days after your State Fair Hearing. For a fast Appeal you will get the Director’s Decision 3 working days after DWS gets all the information from Health Choice Utah. If you lose the State Fair Hearing, the Director’s Decision will also tell you if you have to pay for the care you got during the State Fair Hearing process.
Receiving Continued Benefits
You can keep getting care during the Appeal and State Fair Hearing process if all the things listed before are true:
- Health Choice Utah stops or limits care if we had said okay to before.
- Your provider ordered the care.
- The length of time of the first okay from Health Choice Utah for your care is not over.
- You ask to keep getting your care.
- You send Health Choice Utah your Appeal before Health Choice Utah stops or limits treatment, or within ten (10) days of the date on the Notice of Action, whichever is later.
- You will continue to get the care until any of the following happens:
- You ask to stop the Appeal or State Fair Hearing.
- You do not ask for continued care and do not ask for a hearing within 10 days from the date that Health Choice Utah sends you the Notice of Appeal Resolution.
- You lost the State Fair Hearing.
- The length of time of the first okay from Health Choice Utah for your care ends.
Please note: You will have to pay for all of the care that you get if you lose the appeal or the State Fair Hearing.
Members are in charge of taking care of their Utah Department of Workforce Services (DWS) ID cards. Using the card in a way that is wrong, such as loaning, selling, or giving it to someone else could result in the loss of eligibility and/or legal action as applied by Federal or State law (42 CFR 455.2). If you witness any misuse of any ID card or any other type of fraud or abuse please contact Member Services, or you can call or write DWS. DWS also has a Member Fraud Hotline you can call at 1-888-ITS NOT OK (1-888-487-6686).
FRAUD is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person. It includes any act that constitutes fraud under applicable Federal or State law (42 CFR 455.2).
ABUSE (of member) means provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the DWS program; or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes recipient practices that result in unnecessary cost to the DWS program (42 CFR 455.2).
What if I know of or think there may be Medicaid fraud?
Medicaid PROVIDER Fraud: If you think a Medicaid provider is involved with fraud, please contact:
The Utah Office of Inspector General (OIG)
Toll Free Hotline: 1-855-403-7283
Medicaid CLIENT Fraud: If you think a Medicaid client is involved with fraud, please contact:
Department of Workforce Services Payment Error Prevention Unit
To Report Provider or Client Fraud, Waste or Abuse: oig.utah.gov
If you have questions or concerns about your healthcare, doctors, covered services, or care you are receiving please call Member Services at 1-877-358-8797