PEHP Prior Authorization Form: Submission, Deadlines, and Appeals

A PEHP prior authorization form is the request your healthcare provider submits to the Public Employees’ Health Program before you receive certain services, equipment, or prescriptions, so PEHP can confirm the treatment is medically necessary and covered under your plan. Your provider completes either the medical/surgical form or a drug-specific pharmacy form, attaches clinical documentation, and faxes or mails it to PEHP’s preauthorization department in Salt Lake City. Skip the step when it is required, and PEHP can deny payment even for care your plan would otherwise cover.¹

When You Need to Submit a Form

PEHP publishes a code-level list of services that require written preauthorization, and the Master Policy governs every coverage determination. The categories that most often trigger a form:

Inpatient admissions, including hospital rehabilitation, skilled nursing, mental health and substance abuse treatment, and long-term acute care. All out-of-network inpatient admissions need approval regardless of type.²
Nonemergency care received outside Utah, other than in designated border areas.¹
Specialty and high-cost medications, injectables, and drugs flagged for safety concerns or cheaper first-line alternatives.³
Durable medical equipment such as wheelchairs, hospital beds, and CPAP machines.¹
All home health services.¹
Facility-based sleep studies. Home-based studies may be covered without one; your provider can confirm.²
Assisted reproductive technology, which requires a physician verification form before services begin.¹

If a service that requires preauthorization is performed without one, PEHP treats the charge as the provider’s financial responsibility, not yours. That said, you want the paperwork done correctly up front so care is not delayed or disputed later.

Picking the Right Form

PEHP uses two separate tracks: one for medical and surgical services, another for drugs.

Medical and Surgical

The medical/surgical preauthorization form is a PDF on PEHP’s provider portal and covers hospital admissions, outpatient procedures, imaging, durable medical equipment, home health, and other non-pharmacy services. Providers can also start a medical preauthorization by phone at 801-366-7755 or 800-753-7754.

Pharmacy

Pharmacy preauthorization forms are posted at pehp.org/MyPehpProviders/PharmacyPreauthForms. Each form is tailored to a specific drug or drug class and asks clinical questions keyed to that medication. If the medication does not have its own dedicated form, PEHP provides a general Case Management Medication Pre-authorization Form as a catch-all.³ GLP-1 medications used for diabetes and weight management have their own dedicated preauthorization page on the PEHP site.

What the Form Requires

Incomplete submissions are the fastest route to delay. Before anything leaves the fax machine, every field needs to be filled and every attachment in place.

Member and Provider Identifiers

Your PEHP member identification number, printed on your insurance card, ties the request to your benefit profile. Your provider also enters their 10-digit National Provider Identifier, the standardized number assigned to every covered healthcare provider under HIPAA.⁴ A missing or mistyped NPI stops the request at intake.

Diagnosis and Procedure Codes

The form asks for ICD-10-CM codes identifying your diagnosis⁵ and CPT or HCPCS codes identifying the specific service, procedure, or supply. If the diagnosis code and procedure code do not line up — a knee brace requested under a shoulder-injury diagnosis, for example — PEHP flags the request during review. If you are coordinating between specialists, confirm everyone is working from the same diagnosis.

Clinical Documentation

Codes alone will not get an approval. PEHP’s reviewers compare your record against the criteria in their medical policies, so the submission needs to include:

Recent office visit notes describing the condition, symptoms, and the reasoning behind the requested service.
Lab results or imaging reports supporting the diagnosis or showing progression.
Treatment history, especially documentation of previous therapies that failed or were inadequate. For specialty medications and surgeries, PEHP generally expects providers to try less expensive or less invasive options first.

Pharmacy forms embed drug-specific clinical questions. Answer every one. A single blank field can produce a denial even when the full clinical picture would support approval, so attach chart notes that back up the answers given.³

Where to Send It

Medical and pharmacy requests go to different departments. Using the wrong number costs days.

Medical and surgical: fax (801) 366-7449, or mail PEHP, 560 East 200 South, Salt Lake City, UT 84102.
Pharmacy: fax (801) 245-7774, or mail PEHP Pharmacy Services, 560 East 200 South, Salt Lake City, UT 84102.³

Providers with access to the PEHP provider portal can also submit and track electronically. As a member, you can check the status of a pending request by logging in at pehp.org/mypehp or calling PEHP customer service at 801-366-7555 (toll-free 800-765-7347).

How Long PEHP Has to Decide

Under ERISA’s claims procedure regulation, PEHP must decide a standard preauthorization request within 15 days of receiving it. The plan can extend that window by another 15 days if it notifies you before the first period closes and explains why, typically because of missing information.⁶

If a delay could seriously jeopardize your life or health, your provider can mark the request urgent. Urgent requests must be decided within 72 hours.⁶ Your provider makes that call, because the plan relies on the treating physician’s clinical judgment about whether the standard timeline poses a medical risk.

An approval notice goes to both you and your provider and includes an authorization number and the date range during which the service must be performed. Preauthorization is not a payment guarantee: coverage still depends on your eligibility and benefit terms when you actually receive care.¹

If PEHP Denies the Request

A denial notice spells out the specific reason and explains your appeal rights. The usual reasons are incomplete documentation, a diagnosis that does not meet PEHP’s medical policy criteria, or a required first-line treatment that was not tried first.

Peer-to-Peer Review

Before or during a formal appeal, your provider can request a peer-to-peer call with the PEHP medical director who reviewed the case. When the denial stems from missing context rather than a true coverage exclusion, this often resolves things in a single phone call. Many providers skip the step because it takes time, so it is worth asking whether yours has tried it.

Internal Appeal

PEHP’s appeal form is on the PEHP website. You complete it, attach documentation that addresses the specific reason for denial, and send it back for a full review. Additional records often change the outcome at this stage: a letter of medical necessity, updated test results, or proof that the required first-line treatment was tried and failed. For urgent appeals, your provider can request an expedited internal review by phone rather than waiting on fax turnaround.

If the request involves mental health or substance use disorder treatment, federal law limits how restrictively PEHP can apply preauthorization. Under the Mental Health Parity and Addiction Equity Act, a plan cannot impose prior authorization on mental health and substance use disorder benefits more stringently than it does on comparable medical and surgical benefits.⁷ If you think your request was handled more restrictively than an equivalent medical one, raise it in the appeal.

External Review

If PEHP upholds the denial after the internal appeal, the Affordable Care Act gives you the right to an independent external review for any denial involving medical judgment, a finding that a treatment is experimental, or a coverage cancellation. You have four months from the date of your final internal denial to file a written request.⁸

An independent reviewer who had no role in the original decision evaluates the case. You can appoint your doctor or another medical professional to file on your behalf. The fee cannot exceed $25, and some processes charge nothing.⁸

1
PEHP. PEHP Medical Master Policy
2
PEHP. PEHP Provider Basics
3
PEHP. Pharmacy Preauthorization Forms
4
Centers for Medicare & Medicaid Services. National Provider Identifier Standard
5
Centers for Disease Control and Prevention. ICD-10-CM
6
eCFR. 29 CFR 2560.503-1 – Claims Procedure
7
Centers for Medicare & Medicaid Services. The Mental Health Parity and Addiction Equity Act
8
HealthCare.gov. External Review