Frequently Asked Questions
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Weekdays, 7 am to 8 pm
Saturdays, 9 am to 2 pm
Who do I call if I have questions?
Our Member Services team is happy to answer your questions. Call 855-442-3234 weekdays, from 7:00 a.m. to 8:00 p.m., and Saturdays, from 9:00 a.m. to 2:00 p.m. TTY users should call 711
How can I learn more about my health benefits?
Read the SelectHealth Community Care Medicaid Member Handbook to learn more about your plan. You may also call Member Services at 855-442-3234.
How do I update my address or phone number?
How do I appeal a claim?
How can I learn more about my pharmacy benefits?
To learn about your pharmacy benefits, see the Pharmacy section in your SHCC Medicaid Member Handbook.
How can I get an exception for drugs not covered under my pharmacy benefits?
Sometimes we can make a special exception. Your doctor can ask for one by sending us a Preauthorization Form and/or a Letter of Medical Necessity.
When do I need preauthorization?
You need preauthorization for these types of care:
- Rehab, transitional care, skilled nursing, and all hospitalizations for non-urgent or
non-emergency health problems
- All non-routine obstetrics (OB) admissions and maternity stays longer than two days for
a normal birth or longer than four days for a C-section
- Certain healthcare tools and prosthetics
- Home healthcare, end-of-life care, and private duty nursing care
- Pain management/pain clinic care
- Certain injectable drugs and specialty drugs
- Cochlear implants
- Organ transplants
If you are not a Medicaid member, please call Member Services or see your member materials for a complete list.
- Rehab, transitional care, skilled nursing, and all hospitalizations for non-urgent or
Why was my claim denied?
A claim may be denied if the service is not covered, we don't have enough data, or if you see a doctor who is not on your plan. If you have questions, call Member Services at 855-442-3234.
Where can I make my payment for claims? How do I make a payment on my claims?
SelectHealth does not take payment for services rendered. Payments should be made to the provider of services, such as your doctor. Please contact your provider or wait to receive a bill from your provider.
How do I submit claims for reimbursement?
You can submit a reimbursement for medical services with your receipt attached by downloading the Medical Claim Reimbursement Form. Generally claims must be submitted within one year from the date of service, though longer time limits do exist in certain circumstances.
Typical processing time for reimbursements is 10 to 30 days. To ensure that your benefits are administered correctly and without delay, complete all of the information on this form. Attach a copy of your receipt to this form. If you are submitting multiple receipts, one reimbursement form is required for each receipt.
Submit claims to:
P.O. Box 30192
Salt Lake City, Utah 84130-0192
Claims submitted without the proper identification numbers may be delayed or returned for additional information.
My claim in My Health shows as pending or pended. What does that mean?
If your claim shows as pending or pended, we’re still working hard to process it for you. Typical claims processing time is 10 to 20 days. If you have a concern, call us and we’ll let you know the exact status.
What is an Explanation of Benefits (EOB)?
What is a Coordination of Benefits (COB)?
When a member is enrolled in more than one plan COB is used to determine which plan processes claims first. Read more about COB in our sample plan documents.
What is an allowed amount?
An allowed amount is the dollar amount allowed for a covered service.
Side note: Have you ever wondered, “If I’m paying toward my deductible, how is my plan saving me any money?” The answer lies in this amount. We contract with providers who participate in a network, and these doctors agree to accept a certain amount for services—they can’t ask you to pay anything beyond the amounts they’ve agreed to for covered services. It’s like a discount on medical services, just for being a member!
What is a subscriber?
A subscriber is the primary account holder on your plan.
What is a deductible?
A deductible is an amount you must pay to doctors and facilities before your plan begins to pay for eligible charges. (But remember, you’re still only paying our allowed amount for covered services from participating providers!) Some categories of benefits may have a separate deductible.
Pharmacy or Rx Deductible: This is a separate deductible that only applies to your prescription coverage. You must pay this amount before your plan begins to pay for prescriptions.
What is coinsurance?
When coinsurance applies, you must pay a percentage of the charges from a provider or facility for covered services. This percentage is called a coinsurance.
What is a copay?
A copay is a fixed amount you must pay the doctor, pharmacy, or facility for services. Most plans have lower copays for primary care providers and higher copays for secondary care providers.
What is an out-of-pocket (OOP) maximum?
An out-of-pocket maximum is the total amount you may pay for services covered by your plan each year. Amounts you pay toward your deductible, coinsurance, and copays apply to your out-of-pocket maximum. Some plans have separate medical and pharmacy deductibles, individual deductibles may vary from family deductibles, and some services may not apply to or may exceed the out-of-pocket maximum.
What is a premium?
A premium is the monthly bill you pay for insurance coverage (to be a member of SelectHealth). It does not apply toward the cost-sharing amounts on your plan such as deductibles or out-of-pocket maximums. An employer may pay a portion of your premium.
What is preauthorization?
Some services require prior approval from SelectHealth. This approval is called preauthorization. In-network (participating) providers will typically get it for you, but if you are seeing an out-of-network (nonparticipating) provider, you need to get it yourself. If a service requires preauthorization and it isn’t obtained, your benefits may be reduced or denied. For a list of services that require preauthorization, see your member materials or call Member Services.
What is a primary care doctor?
A primary care doctor or Primary Care Physician (PCP) is a doctor who sees you for common medical problems, performs routine exams, and helps prevent or treat illness. Seeing the same doctor for most visits will help you establish a relationship that can improve your care. The providers—and their physician’s assistants and nurse practitioners—who are considered PCPs by SelectHealth are:
- Family practitioners
- General practitioners
- Internal medicine doctors
- Obstetricians and Gynecologists (OB/GYNs)
What are excess charges?
Excess charges are any dollar amounts that exceed the allowed amount for a covered service. If you are using a participating provider, they will not ask you to pay this amount (this is called a write off). If you see a nonparticipating provider, you are responsible to pay any excess charges.
Online Tools (My Health)
How do I sign up for paperless communications?
Log into My Health and visit the claims section. You must be the plan subscriber to sign up. If you are a dependent on the plan, encourage your subscriber to choose to go paperless.
When you choose to go paperless, you consent that we can send electronic communications. Not all member communications are currently available electronically, but you consent to the electronic receipt of the available materials, and to other materials as they become available.
How can I better understand my medical benefits?
Does SelectHealth have a mobile app?
Yes. The SelectHealth mobile app gives you access to your health plan whenever—and wherever—you need it.
With the mobile app you can:
- View, email, and fax your ID card.
- View your benefits and claims.
- Track your usage with running totals of your deductibles, out-of-pocket maximums, and
- Locate pharmacies and search for covered medications.
- Locate urgent care facilities near you.
- See wait times and reserve your place in line for Intermountain InstaCare facilities
Download the SelectHealth mobile app for your tablet or smartphone:
Apple App Store
Requires iOS 6.0 or later. Compatible with iPhone, iPad, and iPod touch.
Google Play Store
Requires Android 4.0.3 and up.
Why does my ID card only show my name? Can I get an ID card for my dependents?
SelectHealth ID cards only show the subscriber's name on the card; however, they can be used by any covered family member.
Can I download a copy of my ID card?
Why is SelectHealth requesting the Social Security Number of someone on my policy?
Federal Law requires SelectHealth to report any insurance coverage that you or your dependents have had this year to the Internal Revenue Service (IRS). Social Security Numbers are part
of this requirement.
To read about the Affordable Care Act and IRS reporting requirements, visit irs.gov/Affordable-Care-Act/Questions-and-Answers-on-Information-Reporting-by-Health-Coverage-Providers-Section-6055.
Log in to My Health to provide Social Security Numbers for you and your dependents.
How can I access the 1095-A form for tax preparation?
The Federally Facilitated Marketplace (FFM) will mail your 1095-A tax form to the address they have on file.
If you have questions about this form, call the FFM at 800-318-2596. They are available 24 hours a day, seven days a week, excluding certain holidays.
Your Health Idaho (YHI) will mail your 1095-A tax form to the address they have on file. If you have questions about this form, call YHI at 844-944-3246 weekdays, 8:00 a.m. to 5:00 p.m.
How can I access the 1095-B form for tax preparation?
If you are enrolled on a Large Employer, Small Employer, or Individual plan, you will receive a 1095-B tax form in the mail. We mail these to our members at the beginning of each year. But if you purchased a plan through the FFM or YHI, you will not receive a tax form from us—please contact them for more information.
This form will also be available to download from your My Health account by early March.
How can I access the 1095-C form for tax preparation?
Certain Large Employers are required to mail a 1095-C tax form directly to employees. If you have questions about this form, please contact your Human Resources department.
How do I cancel my medical/dental policy? How do I make changes to my medical/dental policy? How do I add my new baby to my plan?
If you purchased an Individual plan through SelectHealth:
• Use a Change Form to make changes to or cancel your health insurance plan. If you are adding eligible dependents, you must do so within 31 days of the child's birth, adoption, or adoption placement.
• If you are on an Individual policy and would like to add your dependent to your health insurance plan, please complete our Individual Plans Change Form. You must do so within 31 days of the child's birth, adoption, or adoption placement.
If you purchased your plan through the Federally Facilitated Marketplace (FFM), you will need to contact them directly to make changes. Call 800-318-2596.
If you purchased your plan through Your Health Idaho (YHI), you will need to contact them directly to make changes to your policy. Call 844-944-3246 weekdays, 8:00 a.m. to 5:00 p.m. MST.
If you receive your health insurance through an employer, you’ll need to contact your Human Resources department to add a dependent. Unfortunately, we are unable to add your dependent
without an update from your employer.
How do I fill a prescription?
On most plans, you have two options for filling prescriptions: Visit a participating pharmacy or get your prescription through Intermountain Home Delivery. Many doctors will e-prescribe your prescription directly to the participating pharmacy (certain medications cannot be e-prescribed) of your choice. If your doctor gives you a paper prescription, take it to a participating pharmacy or call the Intermountain Home Delivery pharmacy.
Can I get a 90-day supply of my medication?
Most plans will allow a 90-day supply of many medications, though some will require you to get it through Intermountain Home Delivery. Ask your doctor to write your prescription for a 90-day supply.
Which drugs or medications are covered by my plan?
How much will my prescription cost?
To find out how much a prescription will cost, log into My Health and click on the SelectHealth icon. From the SelectHealth section, click on Rx Claims. Use the Drug Cost Lookup to search for a medication.
Note: Prices are calculated based on quantity. You may receive the greatest savings when you fill a prescription for a 90-day supply. Cost may vary depending on the pharmacy.
Why wasn’t my drug covered?
There could be a few reasons why your drug was not covered. To view your pharmacy claims, Log into My Health , click on the SelectHealth icon, and choose Rx Claims. If you have questions about a denial, please call us so we can help you understand your coverage or determine why a drug was not covered.
What is a generic drug?
A generic drug is made by a competing drug company after the original maker’s patent has expired. The U.S. Food and Drug Administration requires generics to have the same dosage, safety, strength, and quality as the original brand-name medication, but generics are almost always less expensive than brand-name drugs. Using generic drugs may save you money.
What is a formulary? What is a prescription drug list?
A formulary, or prescription drug list, is a list of the drugs covered by your health insurance plan. Log into My Health to view a searchable list.
What is step therapy?
If a drug requires step therapy, your doctor must first prescribe alternative options that are generally more cost effective. (It typically applies to brand-name drugs.) A medication may be covered without step therapy if determined to be medically necessary. Your doctor can request an exception.
What are quantity limits?
Quantity limits apply to certain drugs for which you can only fill a limited number of tablets or capsules per prescription. Preauthorization is required if the quantity of the prescribed drug exceeds plan limits.
Drug Exception Time Frames and Enrollee Responsibilities
I’m on an Individual plan. What is my formulary and how does it work?
All Individual plans include our RxCore formulary (Utah) (Idaho). A formulary is a list of covered prescription drugs. In an effort to help keep your costs as low as possible, RxCore excludes more expensive brand-name drugs when there is a lower-cost generic option or over-the-counter equivalent available. A generic drug is a medication with the same active ingredients, safety, dosage, quality, and strength as its brand-name counterpart. Providers and pharmacists agree that generic medications are as safe and effective as brand-name drugs.
Individual plan RxCore pharmacy benefits have four tiers (levels) of coverage. Each tier includes different drugs and copays/coinsurance. Tier 1 medications are available at the lowest cost. On some plans, the pharmacy deductible does not apply to these drugs.
Certain medications are not covered. If you have questions before applying for coverage or using your pharmacy benefits, call Member Services or visit the Pharmacy section of our website. You may also search our list of covered medications online or call to request a copy.
Member Rights and Privacy Practices
What are my rights and responsibilities as a member?
How does SelectHealth protect my privacy?
We take your privacy seriously. Read your Notice of Privacy Practices.
Out of Network Liability
What if I received services from an out-of-network provider?
If you receive services from a provider that isn’t on your network, you may be responsible for more charges than had you received the same services from an in-network provider. Out-of-network providers may bill you directly for charges that aren’t covered by your plan. Learn more about Network Providers.
Recoupment of Overpayments
What happens if I overpay my premium?
If you pay too much (overpay) toward your premium and your policy is still active, we will apply this overpayment to the next month’s premium. If your policy has been terminated, the overpayment will be refunded—unless benefits were used after the termination date, in which case, the refund will be offset by the benefits used and we will refund any remaining amount. If you have questions, call 844-442-4106, option 3.
What happens if my policy is canceled but I had claims pending?
If your policy is canceled, any claims submitted during the grace period or before the plan was canceled (when the member was not eligible) will be denied. Some exceptions apply for those with an advanced premium tax credit (e.g., APTC policies include a 90-day grace period. Claims submitted during the first 30 days of the grace period will be paid while claims submitted during the latter 60 days of the grace period will be pended during the grace period and denied if your policy is canceled for non-payment). You can prevent claims pending and retroactive denials by always paying your full premium. Learn more about Retroactive Denials and Grace Periods.
How does SelectHealth make coverage decisions about new technologies and services?
Emerging healthcare technologies (e.g., procedures, devices, tests, and “biologics”) go through a formal process and review by our M-Tech Committee for the purpose of establishing benefits. Existing technologies are also examined through this process.
Access to Rural Healthcare
I live in a rural area. Can I see a doctor who is not on my network?
You may be entitled to coverage for health care services from the following nonparticipating providers if you live or reside within 30 paved road miles of the listed providers, or if you live or reside in closer proximity to the listed providers than to our participating providers:
- Brigham City Community Hospital, Brigham City, Box Elder County, Utah
Federally Qualified Health Centers
- Beaver Medical Clinic, Beaver, Beaver County, Utah
- Blanding Family Practice/Blanding Medical Center, Blanding, Utah
- Bryce Valley Clinic, Cannonville, Utah
- Carbon Medical Services, Carbon, Carbon County, Utah
- Circleview Clinic, Circleview, Piute County, Utah
- Duchesne Valley Medical Clinic, Duchesne, Duchesne County, Utah
- Emery Medical Center, Castledale, Emery County, Utah
- Enterprise Valley Medical Clinic, Enterprise, Washington County, Utah
- Garfield Memorial Clinic, Panguitch, Garfield County, Utah
- Green Valley/River Clinic, Green River, Emery/Grand Counties, Utah
- Halchita Clinic, San Juan County, Utah
- Hurricane Family Practice Clinic, Hurricane, Washington County, Utah
- Kamas Health Center, Kamas, Summit County, Utah
- Kazan Memorial Clinic, Escalante, Garfield County, Utah
- Long Valley Medical, Kane County, Utah
- Milford Valley Clinic, Milford, Beaver County, Utah
- Montezuma Creek Health Center, Montezuma Creek, San Juan County, Utah
- Monument Valley Health Center, Monument Valley, Utah
- Navajo Mountain Health Center, San Juan County, Utah
- Wayne County Medical Clinic, Bicknell, Wayne County, Utah
This list may change periodically, please check on our website or call for verification. Please be advised that if you choose a nonparticipating provider, you will be responsible for any charges not covered by your health insurance plan.
If you have questions concerning your rights to see a provider on this list, contact Member Services at 800-538-5038.
If we cannot resolve your problem, you may contact the Office of Consumer Health Assistance in the Utah Insurance Department, toll free.
What does SelectHealth do to keep health insurance premium rates affordable?
The process for reviewing a request for coverage can be called preauthorization, prior authorization, or simply, ‘authorization’. There are different types of authorizations:
- A concurrent authorization or concurrent review is done while you are receiving care. For example, if you are already in the hospital.
- A post-service authorization is obtained after a service has been provided. An example is emergency care, when it is not safe or reasonable to wait for authorization before obtaining treatment.
What are some examples of procedures that may require preauthorization?
A preservice authorization is obtained before a service is provided. For example, planned or scheduled surgery.
- Preauthorization is required for all the following: all admissions to facilities, including rehabilitation, transitional care, skilled nursing, and all hospitalizations that are not for urgent or emergency conditions; all nonroutine obstetrics admissions and maternity stays longer than two days for a normal delivery or longer than four days for a cesarean section; certain durable medical equipment and prosthetics; home healthcare; hospice and private duty nursing services; all services obtained outside of the United States unless a routine, urgent or emergency condition; pain management/pain clinic services; certain injectable drugs and specialty medications; cochlear implants; organ transplants; and selected prescription drugs.
To see a list of all services that require authorization, or to request authorization for medical care, you can call Member Services at 800-538-5038. We are available weekdays, from 7:00 am to 8:00 pm, and Saturdays, from 9:00 am to 2:00 pm. TTY users should call 711.
Why is it important to receive preauthorization?
If you fail to preauthorize these services when using a nonparticipating provider your benefits may be denied or reduced by 50 percent and will not be applied to your out-of-picket maximum.