Section I - General Information
The Utah Medicaid Program pays medical bills for people who have low incomes or cannot afford the cost of health care and who are found eligible for the program. The program is based on a medical need. The Utah Medicaid program is administered by the Utah Department of Health and Human Services, Division of Integrated Healthcare. The Utah Medicaid Provider Manual contains the coverage policy for the fee-for-service Medicaid Program. The manual consists of several distinct sections, attachments, and periodic published updates as described below.
Section 1 of the provider manual provides general information about the Utah Medicaid Program to assist enrolled providers with submitting claims for services rendered to Utah Medicaid members. Use Section 1 in conjunction with the other more specific provider manual sections, attachments and forms. Providers and their staff should familiarize themselves with these documents and refer to them to answer program and billing questions. This will reduce misunderstandings concerning the coverage of services, member eligibility, and proper billing procedures, which can result in payment delays, incorrect payments, or payment denials.
The information in the Utah Medicaid Provider Manual represents available services when medically necessary. Each Section outlines covered services as well as limitations. At times services may be more limited or may be expanded, using the utilization review process, if a proposed service is medically necessary and more cost effective than alternate services.
Utah Medicaid makes every attempt to ensure that the information contained in each section of the manual is current and reliable. The contents of the Utah Medicaid Provider Manual are updated regularly. Sections with changes are published and a report of the changes is published in the Medicaid Information Bulletin (MIB). The MIB is emailed to enrolled providers who subscribe to the Medicaid newsletter. To receive the newsletter, sign up on the "Utah Medicaid Official Publications" page at the Medicaid website. For additional information on obtaining updated information, refer to the Utah Medicaid website, https://medicaid.utah.gov, or contact medicaidops@utah.gov.
Payment for services is made in accordance with the policy and fee schedule in effect at the time services are rendered. The provider rendering services is responsible to be aware of and comply with the policies and procedures in the Utah Medicaid Provider Manual, the MIBs, the Coverage and Reimbursement Lookup Tool, and applicable policies and procedures of managed care plans.
Compliance with all applicable Utah state laws, regulations, and administrative guidelines is required of all providers. In particular, providers must adhere to the Utah Administrative Code R414-1, Utah Medicaid Program, which generally describes the Medicaid program. This rule incorporates by reference the Utah Medicaid Provider Manual. Therefore, you must consider the content of the provider manuals along with applicable federal and state laws and regulations. If you have questions or need further information, refer to the Medicaid website, or contact Medicaid (Refer to this Chapter, Medicaid Contact Information).
Annually a statewide provider training is offered. The training covers significant changes in Medicaid and other topics of concern to the provider as well as question and answer time. Refer to the Utah Medicaid website for dates at https://medicaid.utah.gov.
Utah Medicaid is a public assistance program providing medical services to individuals meeting certain income, resource, and eligibility criteria. Established by Title XIX of the Social Security Act, it is administered by the State of Utah and financed jointly by state and federal funds. At the federal level, the program is administered by the Centers for Medicare and Medicaid Services (CMS) within the U.S. Department of Health and Human Services, which provides funding to the states, establishes minimal program requirements, and provides regulatory oversight. Federal guidelines are designed to ensure the states administering Medicaid programs provide appropriate, medically necessary quality health care services for all members, while maintaining financial accountability. State funds are appropriated by the Utah Legislature. Utah’s Medicaid program is administered by the Utah Department of Health and Human Services, Division of Integrated Healthcare, which is the single state agency responsible for administering the program.
Each state establishes and administers its own Medicaid program, and determines the type, amount, duration and scope of services covered within broad federal guidelines. States must cover certain mandatory benefits and may choose to provide other optional benefits. Federal law requires states to cover certain mandatory eligibility groups, including qualified parents, children and pregnant women with low income, as well as older adults and people with disabilities with low income.
Utah Medicaid establishes eligibility standards for Medicaid providers, determines benefits, sets payment rates, and reimburses providers. Medicaid maintains the State Plan and files amendments to the plan (state plan amendments, or SPA) with appropriate regulatory authorities.
Although this Section does not cover in detail, policies to determine if an individual is eligible for Medicaid, the following information provides a general summary of the member application process, a description of the member guide, and how to access to Medicaid constituent services which may be useful information for providers.
Individuals seeking assistance for payment for medical services may apply online at https://medicaid.utah.gov/apply-medicaid. Medicaid applications are available in English and Spanish. Application may also be made through the Department of Workforce Services (DWS) or outreach offices in most major hospitals and many area public health clinics. Call DWS Customer Relations at (801) 526-0950 or 1(866) 435-7414, or to find a local outreach office, go to http://jobs.utah.gov. The DWS offices also assist individuals who are seeking other types of assistance, including food stamps, financial assistance, and childcare assistance.
Individuals needing assistance with the application process may call the above DWS Customer Relations number. For additional information on applying for Medicaid, refer to the Medicaid website at https://medicaid.utah.gov.
Internet
The Medicaid website address is https://medicaid.utah.gov.
Telephone - Medicaid Information:
|
Salt Lake City area |
(801) 538-6155 |
|
Utah, Idaho, Wyoming, Colorado, New Mexico, |
1(800) 662-9651 |
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From other states |
1(801) 538-6155 |
Medicaid Information has a telephone menu to reduce waiting time and the number of transfers for Medicaid providers and members.
Customer service representatives are available:
| Monday, Tuesday, Wednesday, Friday |
8:00 A.M. to 5:00 P.M. |
| Thursday Closed on all state and federal holidays. |
11:00 A.M. to 5:00 P.M. |
FAX Numbers
Each Medicaid team has its own FAX line in order to provide better customer service. The FAX numbers are located with the General Attachments at https://medicaid.utah.gov/utah-medicaid-official-publications/.
Mailing Address for Medicaid Claims (Claims sent by mail must be sent by U.S. Postal Service)
Office of Medicaid Operations
PO Box 143106
Salt Lake City, Utah 84114-3106
Street Address
Department of Health and Human Services
288 North 1460 West
Salt Lake City, Utah 84114
Note: The Department of Health and Human Services (the Martha Hughes Cannon Building) is a secure building. Public access is restricted to the lobby area, cafeteria, Vital Records, and a designated conference room, all located on the first floor. Access to other areas of the building requires an employee escort. State and Federal privacy laws do not permit staff at the Martha Hughes Cannon Building’s information desk, or any other reception desk in the building, to handle Medicaid claims.
The information booklet, “Medicaid Member Guide,” is mailed to all new members. The guide explains the Medicaid program including rights and responsibilities, selection of a health care provider, and health care services covered by Medicaid. The Medicaid Member Guide may also be obtained by calling 1(866) 608-9422 or on the Medicaid website at http://health.utah.gov/umb/forms/pdf/Medicaid_Member_Guide.pdf. The guide can be read, printed, or saved from this screen.
The Division of Integrated Healthcare (DIH) issues a wallet-sized plastic Medicaid Member Card to members eligible for Traditional Medicaid, Non-Traditional Medicaid, Baby Your Baby, or Hospital Presumptive Eligibility. The card is the same for each program. Possession of the card does not guarantee a member’s eligibility for any of these programs. It is the provider’s responsibility to use the information on the card to verify program and eligibility information.
The Medicaid Member Card has the member’s name, Medicaid ID number, and date of birth. The back of the card has contact information and websites useful to both providers and members. The member must present the card with a photo identification at each service.
To view a sample Medicaid Member Card, go to: https://medicaid.utah.gov/Documents/pdfs/Medicaidcard_FINAL_sample%20(1).pdf
Medicaid members also receive a benefit letter in the mail. The letter has eligibility and plan information. When there are changes, Medicaid sends a new benefit letter.
A member’s eligibility for Medicaid, Baby Your Baby, or Hospital Presumptive Eligibility may change from month to month. Additionally, most Medicaid members are enrolled in a managed care organization to receive their services. Before providing services to a Medicaid member, providers are responsible for determining a member’s eligibility and whether the member is enrolled in an MCO. Eligibility and plan enrollment information for each member is available to providers from these sources: Eligibility Lookup Tool, AccessNow, or ANSI 270 or ANSI 271. Refer to Chapter 6, Member Eligibility for additional information and links.
The Medicaid Provider Manual contains information regarding Medicaid policy and procedures for fee-for-service Medicaid members. Managed Care Organizations (MCO) must provide the services outlined in the applicable Sections as well as the applicable services described in the Utah Medicaid State Plan. However, MCOs may have different prior authorization requirements and post-payment review requirements. Providers who render services to members enrolled in MCOs should contact the MCO or refer to the MCO's manual for additional information. If a Medicaid member is enrolled in an MCO, they must receive services through that MCO.
At times there are exceptions to MCO coverage. Service exceptions are called “carve-out services,” which may be billed directly to Medicaid on a fee-for-service basis. Medicaid will deny fee-for-service claims submitted directly to the DIH, unless payment for the service is not the responsibility of the MCO. In such cases the claim is considered for payment under the requirements found in this and other applicable Sections.
To determine if a member is enrolled in an MCO, or if services may be billed to DIH on a fee-for-service basis, providers must verify member eligibility using one of the following tools: Eligibility Lookup Tool, AccessNow (touch tone telephone verification) or, ANSI 270 or ANSI 271, an online service, for providers enrolled in the Utah Health Information Network (UHIN). Refer to Chapter 6, Member Eligibility for links and more information or go to the Medicaid website, https://medicaid.utah.gov/.
Medicaid members not enrolled in an MCO and not enrolled in DIH’s Restriction Program, may receive services from any qualified provider who accepts Medicaid.
For general member concerns, contact the Utah Department of Health and Human Services, Division of Integrated Healthcare, Constituent Services representative at medicaidmemberfeedback@utah.gov or (801) 538-6417 or toll free at 1(877) 291-5583.
For concerns related to a managed care organization, contact the MCO first. If the concern is unresolved, contact a state DIH Health Program Representative at 1(866) 608-9422.
Following is a list of definitions relevant to the administration, policies, and procedures of the Utah Medicaid Program:
Accountable Care Organization (ACO): A physical health plan that contracts with Utah Medicaid to provide services to Medicaid clients.
Assigned Claim: A claim for which the provider accepts the Medicare assignment of payment.
Assistant to Surgery: A physician or non-physician practitioner who actively assists the physician in charge of a case in performing a surgical procedure.
Accredited Standards Committee (ASC X12): An ANSI accredited standards organization responsible for the development and maintenance of electronic data interchange (EDI) standards for many industries. The “X12” or insurance section of ASC X12 handles the EDI for the health insurance industry’s administrative transactions. Under HIPAA, X12 standards have been adopted for most of the transactions between health plans and providers.
Baby Your Baby (BYB): This program provides temporary Medicaid coverage for qualified low-income pregnant women prior to establishing eligibility for ongoing Medicaid. Members apply for the program through a qualified BYB provider and qualify based on preliminary information provided on the BYB application.
Carve-out Service: Services not included in the Medicaid contract with an MCO (ACO, PMHP or dental plan.)
Clinical Laboratory Improvement Amendments (CLIA): The federal Centers for Medicare and Medicaid Services (CMS) program which limits reimbursement for laboratory services based on the equipment and capability of the physician or laboratory to provide an appropriate, competent level of laboratory service.
Code of Federal Regulations (CFR): The publication by the Office of the Federal Register, specifically Title 42, used to govern the administration of the Medicaid program. Federal rules promulgated by the Centers for Medicare and Medicaid Services (CMS) place requirements upon the state Medicaid agency, Medicaid providers, and recipients.
Covered Medicaid Service: Service available to an eligible Medicaid member within the constraints of the Utah Medicaid Program and criteria for approval of service.
Current Procedural Terminology Manual (CPT): The manual published by the American Medical Association that provides a systematic listing and coding of procedures and services performed by physicians and simplifies the reporting of services to third party payers.
Diagnosis Related Group (DRG): The system established to recognize and reimburse for the resources used to treat a client with a specific diagnosis or medical need. The Federal DRG relative weight, average length of stay (ALOS), and outlier threshold days are extracted from Utah Medicaid paid claims history files or from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS).
Division of Integrated Healthcare (DIH): The organizational division in the Utah Department of Health and Human Services which administers the Medicaid program in Utah.
Early Periodic Screening Diagnosis and Treatment (EPSDT): The federal preventive health care services program for children, formally known as the Child Health Evaluation and Care (CHEC) Program. (For Medicaid members enrolled in Traditional Medicaid ages birth through twenty.)
Enrolled Provider: A licensed practitioner of the healing arts or an entity providing approved Medicaid services to patients under a provider agreement with the Department.
Explanation of Benefits (EOB): The form sent by a liable third party to a provider to explain whether a claim is paid and the amount paid or denied and the reason denied.
Explanation of Medicare Benefits (EOMB): The form received by the provider from Medicare to explain whether a claim is paid, the amount paid, or denied and the reason denied.
Federal Financial Participation (FFP): The Medicaid program is funded jointly by the federal government and the state. FFP is the specified percentage the federal government pays the state for Medicaid program expenditure.
Federal Poverty Level (FPL): The set minimum amount of gross income that a family needs for food, clothing, transportation, shelter, and other necessities. This level varies by household size. FPLs are used to determine financial eligibility for certain federal programs. The guidelines are issued each year in the Federal Register by the Department of Health and Human Services (HHS). The Federal Poverty Level is available on the Internet at http://aspe.hhs.gov/poverty/index.shtml.
Fee-for-Service: Medicaid covered services that are billed directly to and paid for directly by Medicaid based on an established fee schedule.
Fee-for-Service Medicaid Member: A member who is not enrolled in an MCO; or is enrolled in an MCO, but the service that is needed is a carve-out service covered directly by Medicaid.
Fraud: Refer to “Medicaid Fraud.”
Healthcare Common Procedure Coding System (HCPCS): The system mandated by the Centers for Medicare and Medicaid Services (CMS) to code procedures and services. This system incorporates the CPT Manual for physicians and individually developed service codes and definitions for non-physician providers.
Hospital Presumptive Eligibility (HPE): The program provides temporary Medicaid coverage for qualified low-income individuals prior to establishing eligibility for ongoing Medicaid. Members apply for this program through a qualified hospital provider and qualify based on preliminary information provided on the application.
Intermediary: An entity which contracts with Centers for Medicare and Medicaid Services (CMS) to determine and make Medicare payments for Part A or Part B benefits payable on a cost basis and to perform other related functions.
International Classification of Diseases (ICD): The source for coding the diagnosis for which a patient is being treated.
Limited Enrollment Provider: Providers who wish only to order, refer, or prescribe and not provide any other services to Medicaid members. This type of enrollment does not allow Medicaid to reimburse the provider for services.
Managed Care Organization (MCO): For the purposes of this manual, means a health, behavioral health or dental plan that contracts with the Medicaid agency to provide services to Medicaid members and attempts to control the cost and quality of care by coordinating services. MCO is sometimes used as a generic term to mean an ACO, PMHP and/or dental plan.
Medicaid: The medical assistance program authorized under Title XIX of the Social Security Act.
Medicaid Agency: The Utah Department of Health and Human Services, Division of Integrated Healthcare.
Medicaid Audit: A civil or administrative process of reviewing Medicaid provider records to ensure accurate billing and payment for Medicaid claims.
Medicaid Fraud: Knowingly, recklessly, or intentionally presenting false information to the Medicaid agency with the intent to receive unauthorized Medicaid benefit for any person or entity. Refer to Utah Code Ann. §26-20-1, et seq. Some examples of fraud include: knowingly or intentionally billing Medicaid for services that were not provided, making a materially false statement in connection with any claim for payment to the Medicaid program, accepting kickbacks or bribes for referrals or services.
Medicaid Fraud Control Unit (MFCU): The official state Medicaid fraud control unit in the Utah Office of the Attorney General, certified by the federal government, to investigate and prosecute complaints of abuse and neglect of patients, and Medicaid fraud under state laws as required by 42 CFR 1007.7 through 1007.13. The MFCU has statewide prosecutorial authority.
Medicaid Information Bulletins (MIB): An official, periodic publication of the Division of Integrated Healthcare to update the Utah Medicaid Provider Manual or issue information to Medicaid providers.
Office of Inspector General: This office, like the MFCU mentioned above, also addresses issues related to fraud, utilization control, audits, and investigations, but is part of the Office of Inspector General.
Medicaid Provider Agreement: A signed contract between a provider and the Utah Medicaid program by which the provider agrees to abide by all state and federal law related to the Medicaid Program, including providing medical and billing records for the purposes of conducting Medicaid and MFCU audits to determine fraud or abuse of the Medicaid program. The provider also agrees to abide by any subsequent amendments to the Agreement published in the Medicaid Information Bulletin. This agreement, together with the recipient’s Medicaid application, authorizes the release of Medicaid records for Medicaid and MFCU auditing purposes.
Medical Necessity: A service is “medically necessary” if it is (1) reasonably calculated to prevent, diagnose, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, or threaten to cause a disability; and (2) there is no other equally effective course of treatment available or suitable for the client requesting the service which is more conservative or substantially less costly. (R414-1-2 (18))
Medicare: The national health insurance program for aged and disabled persons under Title XVIII of the Social Security Act. Part A includes hospital and nursing home services. Part B pays professional fees, such as physicians, physical therapy, etc.
Member: The preferred term to refer to a person who is eligible for the Utah Medicaid Program. “Member” is often used interchangeably with "client," “recipient,” “patient,” or “enrollee” when the person is eligible for the Utah Medicaid Program.
Non-Physician Practitioner: A non-physician practitioner is a healthcare provider practicing either in collaboration with or under the supervision of a physician, including physician assistants and nurse practitioners.
Non-Traditional Medicaid: A medical plan based on the Traditional Medicaid Plan but additional limitations and/or restrictions are imposed, under a waiver of federal regulations, on benefits and services of Traditional Medicaid as covered by the Medicaid State Plan. Members eligible for Non-Traditional Medicaid includes: adults on Family Medicaid programs (adults with dependent children) and adult caretaker relatives on Family Medicaid. Services are based on the program type a person is eligible to receive. For services covered under NTM please refer to the Administrative Rule UT Admin Code R414-200. Non-Traditional Medicaid Health Plan Services and the Coverage and Reimbursement Code Lookup.
Nurse Practitioner: A nurse practitioner (NP) is an individual who performs professional services within their scope of licensing, under Utah Code, Title 58: Occupations and Professions, Chapter 31b: Nurse Practice Act.
Overpayment: Refer to “Provider Overpayment.”
Patient: An individual awaiting or receiving professional services directed by a licensed practitioner of the healing arts, also referred to as a Medicaid member or member.
Physician: A doctor of medicine or osteopathy legally authorized to practice medicine or surgery in the state.
Physician Assistant: A physician assistant (PA) is an individual who performs professional services within their scope of licensing, under Utah Code, Title 58: Occupations and Professions, Chapter 70a: Utah Physician Assistant Act.
Prepaid Mental Health Plan (PMHP): The Medicaid mental and substance use disorder managed care plan operating under the authority of the Department's 1915(b) waiver.
Presumptive Eligibility: Provides temporary Medicaid coverage for qualified low-income individuals prior to establishing eligibility for ongoing Medicaid. Presumptive eligibility programs include the Baby Your Baby program and the Hospital Presumptive Eligibility program.
Prior Authorization (PA): Required approval obtained by a health care provider from Medicaid (the Division of Integrated Healthcare, Department of Health and Human Services) or from an MCO, if applicable before certain services are rendered.
Provider: An entity or licensed practitioner of the healing arts furnishing medical, mental health, dental or pharmacy services.
Provider Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices resulting in unnecessary Medicaid costs. Reimbursement for services that are not medically necessary, failure to meet professionally recognized standards of care, or any similar practice that results in increased costs to Medicaid are also considered abuse. Criminal intent need not be alleged nor proved to establish abuse.
Provider Agreement: Refer to “Medicaid Provider Agreement.”
Provider Overpayment: An overpayment occurs when a Medicaid provider receives more Medicaid reimbursement than the provider is entitled, regardless of which party is at fault.
Recipient: A person who is eligible for the Utah Medicaid Program and eligible to receive covered Medicaid services from an enrolled Medicaid provider also known as a member.
Reimbursement: An established amount of money paid to a provider in exchange for a specifically defined and coded service provided to a Medicaid client.
Remittance Statement: The explanation from Medicaid as to claims which have been paid, denied or are in process.
Restricted Member: A Medicaid member who is enrolled in the Restriction Program due to unnecessary overutilization of their Medicaid Benefit. Restricted members are locked-in to one Primary Care Provider (PCP) who can authorize specialty providers as needed and are also locked-in to one pharmacy.
Restriction Program: Provides safeguards against inappropriate and excessive use of Medicaid services.
Services: The types of medical assistance specified in Sections 1905(a)(1) through (25) of the Social Security Act and interpreted in 42 CFR §440 [October 1, 1996, edition].
Single State Agency: The agency which administers the Medicaid program in the State of Utah is the Utah Department of Health and Human Services, Division of Integrated Healthcare.
Third Party Liability (TPL): The responsibility of an individual, entity, or program which is or may be liable to pay all or part of the medical cost of injury, disease, or disability of a patient.
Title XIX: The Medicaid Program authorized by the Federal Social Security Act.
Traditional Medicaid: A medical plan that will pay for many medical services for eligible individuals. Individuals eligible for Traditional Medicaid include: children; pregnant women; aged, blind or disabled adults; women eligible under the cancer program. Some services are available only to children and to pregnant women under Traditional Medicaid.
Utah Department of Health and Human Services: The single state agency designated to administer or supervise the administration of the Medicaid Program under Title XIX of the federal Social Security Act. All references to "the Medicaid agency" mean the Department of Health and Human Services. Reference: Utah Code Annotated §26-18-2.1 (1953, as amended) and Utah Administrative Code, Rule R414-1-2.
Utah Health Information Network (UHIN): (1) a coalition of insurers, providers, the Utah Medical Association, the Utah Hospital Association, and State Government which developed an electronic data exchange to centralize transactions for providers and payers, including Medicaid. (2) The electronic data exchange, also referred to as UHIN or the UHIN network.
Year: Any 12-month period of time unless specified as a calendar year.
This section provides summary information about Utah Medicaid managed care; types of managed care entities (MCEs); member enrollment and disenrollment; services covered and not covered by MCEs; and grievances and appeals related to MCEs.
Managed care is a health care delivery system organized to manage cost, utilization, and quality. Medicaid managed care provides for the delivery of Medicaid benefits through contract arrangements between the Division of Integrated Healthcare (DIH) and MCEs. DIH contracts with MCEs to provide physical health care, behavioral health care (mental health and substance use disorders), dental care, and pharmacy services for Medicaid members. DIH pays a monthly premium for each Medicaid member enrolled in the MCE. The MCEs are responsible for the services specified in their contracts with DIH.
The following types of MCEs provide services to Utah Medicaid managed care enrollees:
Medicaid members enrolled in MCEs are entitled to the same Medicaid benefits as Fee-for-Service Members. However, MCEs may offer additional benefits and may have different prior authorization requirements than the Medicaid Fee-for-Service scope of benefits. A Medicaid member enrolled in an MCE must receive services through that MCE, with some exceptions called “carve-out services”. The MCE pays providers for services covered under the MCE’s contract. DIH pays providers for services that are carved out of MCE contracts.
Specific Medicaid members are required to enroll in two of the types of MCEs (ACOs and dental plans). If the member lives in one of the counties in which enrollment is mandatory, the member must choose an ACO or dental plan, or both.
Enrollment in a PMHP is based on the county in which the member resides. Members do not choose a PMHP but are automatically enrolled with the PMHP(s) serving their county of residence. Members must receive behavioral services through their assigned PMHPs.
HOME is a voluntary program and therefore, members may choose to enroll in HOME if they meet certain criteria.
Health Program Representatives (HPRs) employed by the DIH educate members on the Utah Medicaid Program, managed care, the ACO and dental MCE options, and the PMHP. In addition, the HPRs help members choose an ACO and dental plan. HPRs are resources for members and providers who may have issues related to MCEs.
The following Medicaid members are not enrolled in MCEs:
Medicaid makes every effort to provide complete and accurate information regarding a member’s enrollment in an MCE. However, it is the provider’s responsibility to verify a member’s eligibility and service delivery model (MCE or Fee-for-Service) before providing services. Eligibility for Medicaid and enrollment in an MCE may change from month to month.
To determine if a Medicaid member is enrolled in an MCE or is a Fee-for-Service member, providers may verify member eligibility using AccessNow, the provider Eligibility Lookup Tool, or ANSI 270/271.
Each MCE is responsible to determine which services require prior authorization and the process providers must use to request authorization of services for Medicaid members enrolled in the MCE. DIH does not process prior authorization requests for services to be provided to a Medicaid member enrolled in an MCE when the services are the responsibility of the MCE. Providers requesting prior authorization from DIH for MCE-covered services for a member enrolled in an MCE will be referred to that MCE.
Each MCE has its own network of providers. Depending on the type of MCE and services that are covered, provider networks can include but are not limited to clinics, hospitals, physicians, dentists, and pharmacies. If a provider wishes to enroll with a specific MCE network, the provider must contact the MCE directly.
Claims for services covered by an MCE must be submitted to the MCE in which the member is enrolled using the methods established by the MCE.
Once per year, between mid-May and mid-June, Medicaid has an open enrollment period during which Medicaid members can change to a different ACO or dental plan effective July 1st of the year. Medicaid members are also allowed to change their ACO or dental plan during the first 90 days after an MCE is chosen or has been assigned. Medicaid members who want to change their ACO or dental plan selection should contact an HPR toll-free at 1-866-608-9422.
Members enrolled in the Medicaid Restriction Program are not eligible to change to a different ACO, including within the ACO open enrollment period. For complete information on the Restriction Program, refer to Chapter 8-3 (Medicaid Restriction Program).
If a member’s enrollment is changed to a different MCEs or Fee-for-Service, approved prior authorizations for medical care from the previous MCE will be honored for the member until:
When a provider receives a PA, the provider must submit the associated claim for the authorized service to the entity that issued the PA (i.e., ACO, PMHP, HOME, dental plan, or DIH).
If a Medicaid member is enrolled in an MCE, DIH will not pay a claim unless it is for a carve-out service. A carve-out service is a service that is covered by Medicaid but not covered by an MCE. Services that are carved out from an MCE differ depending upon the type of MCE.
Listed below are carve-out services that are not covered by any of the MCEs. These services are paid by DIH:
*ACOs, PMHPs or HOME may be responsible for transportation in some situations. Contact the MCE to determine responsibility for coverage.
DIH contracts with four ACOs: Health Choice Utah, Healthy U, Molina Healthcare, and SelectHealth Community Care. Not all ACOs are available in every county. There are from two to four ACOs available in each county.
Medicaid requires most Medicaid members living in the following counties to enroll with an ACO: Box Elder, Cache, Davis, Iron, Morgan, Rich, Salt Lake, Summit, Tooele, Utah, Wasatch, Washington, and Weber.
In addition to the Medicaid members listed in the Members Not Enrolled in MCEs section above, members who are admitted to a skilled nursing facility, intermediate care facility or a Long-Term Acute Care Hospital for a long term stay (i.e., a stay intended to last more than 30 days) will be disenrolled from the ACO. Disenrollment due to a long-term stay requires notification to DIH. In addition, Medicaid members enrolled in Utah’s Buyout Program do not have to enroll in an ACO.
Other than the excluded members above, when determined eligible for Medicaid, a member residing in one of the counties specified above must select an ACO.
ACOs cover most Medicaid-covered services with the exception of behavioral health and dental. In addition, the ACOs do not cover the carve-out services listed in the MCE Carve-Out Services section above.
Members enrolled in an ACO may need to be in the Restriction Program due to possible abuse or misuse of Medicaid services. A member enrolled in the Restriction Program must receive services provided by one PCP and one pharmacy, unless otherwise authorized by the PCP.
Referrals for possible enrollment in the Restriction Program may be submitted to medicaidrestriction@utah.gov or 801-538-9045 or to the ACO in which the member is enrolled. For complete information on the Restriction Program, refer to Chapter 8-3 (Medicaid Restriction Program).
DIH contracts with local county mental health and substance abuse authorities or their designated entities (as PMHPs) to provide inpatient hospital psychiatric services and outpatient mental health and outpatient substance use disorder services to Medicaid members.
The PMHPs cover most counties of the state. Medicaid members are automatically enrolled with the PMHP serving their county of residence. Members must receive inpatient and outpatient mental health services and outpatient substance use disorder services through their assigned PMHP.
In Box Elder, Cache and Rich counties, outpatient substance use disorder services are not covered under the PMHP. Medicaid members living in one of these counties may obtain outpatient substance use disorder services from any qualified Medicaid provider and providers may bill DIH. Medicaid members living in any of these counties are enrolled in the PMHP for mental health services, and must obtain their mental health services through the PMHP contractor serving these counties.
Wasatch County is not covered under the PMHP. Medicaid members living in Wasatch County may obtain mental health and substance use disorder services from any qualified Medicaid provider. Providers may bill DIH.
Exceptions to PMHP enrollment are:
PMHPs are responsible for inpatient hospital psychiatric services when they are performed on an inpatient basis under the direction of a physician for a psychiatric condition manifesting itself with a sudden onset. At the time of the inpatient admission, the psychiatric condition should be of such a nature as to pose a significant and immediate danger to self, others, or public safety, or which has resulted in marked psychosocial dysfunction or grave mental disability of the patient. PMHPs are also responsible for electroconvulsive therapy (ECT) and related charges.
PMHPs are not responsible for pharmacy services. In addition, the PMHPs do not cover the carve-out services listed in the MCE Carve-Out Services section above.
Medicaid members enrolled in the PMHP may get services directly from a federally qualified health center (FQHC). PMHP prior authorization is not required. FQHCs may bill DIH.
The Healthy Outcomes Medical Excellence program (HOME), operated by the University of Utah, is a voluntary MCE for Medicaid members who have a developmental disability and mental health or behavioral challenges.
HOME is a coordinated care program that provides services normally covered by the ACOs and the PMHPs. HOME is not responsible for pharmacy services. When Medicaid members enroll in HOME, they are disenrolled from their ACO and PMHP.
Medicaid covers full dental services for the following Traditional Medicaid members who:
DIH contracts with two dental plans, MCNA Dental and Premier Access, to deliver dental services.
Medicaid members who are eligible for full dental services are required to be enrolled in a dental plan except those eligible for the following Medicaid programs:
Dental plans cover most Medicaid dental services. General anesthesia performed at a hospital or ambulatory surgical center are carved out of the dental plans. Medical and surgical services of a dentist performed at a hospital or ambulatory surgical center are carved out of the dental plans. In addition, the dental plans do not cover the carve-out services listed in the MCE Carve-Out Services section above.
All MCEs cover emergency services for members 24 hours a day, seven days a week whether or not the services are provided within the MCE’s provider network.
When an MCE makes a decision that constitutes an adverse benefit determination, a member, provider, or an authorized representative, may request an appeal with the MCE. An appeal is a review by an MCE of an adverse benefit determination. Examples of MCE adverse benefit determinations are:
The timeline to request an appeal with the MCE is within 60 calendar days from the date on the notice of Adverse Benefit Determination. If the MCE’s appeal resolution is not wholly in favor of the member, the member or provider may request a State fair hearing with DIH no later than 120 calendar days from the date of the MCE’s notice of resolution. The hearing request form can be found at https://medicaid.utah.gov/utah-medicaid-forms.
Members, providers, or authorized representatives must exhaust the MCE’s appeals process prior to requesting a State fair heating.
A grievance means an expression of dissatisfaction about any matter other than an adverse benefit determination. Examples of grievance are:
Grievances may be filed with an MCE at any time by a member, provider, or authorized representative. A grievance should be submitted to the MCE. Aggrieved parties may also contact the DIH Constituent Services representative at medicaidmemberfeedback@utah.gov or 801-538-6417 or toll-free at 1-877- 291-5583 to discuss the grievance.
This chapter covers topics such as provider agreement, co-payments, prohibition on billing clients, record keeping, provider sanctions, and audits.
There are general requirements which must be met for a provider to participate in the Medicaid Program. Any provider of health care services must be enrolled in the Utah Medicaid Program, will only render services within their scope of licensure, before Medicaid will cover any services provided by the provider to Medicaid members. Enrollment as a Medicaid provider is contingent upon the provider satisfying all rules and requirements for provider participation as specified in the applicable Section of this Provider Manual, and state and federal law. Section 2 of this manual, which comprises several individual manuals, contains additional requirements for each specific provider type. Medicaid can reimburse a provider who satisfies all credential requirements for each provider type, completes and signs the Utah Medicaid Provider agreement, and receives notice from the Utah Medicaid Program of acceptance.
Keep Medicaid informed of any address changes. Returned mail will result in your provider agreement being closed. Medicaid may close providers who have not billed Medicaid for one or more years without notification.
A provider enrolls as a Medicaid Provider by completing the Medicaid Provider Application and signing the Provider Agreement. A provider must execute the Agreement before they are authorized to furnish Medicaid services. When the State accepts the provider’s application and the agreement is signed, the State will notify the provider by approval letter with the effective date of enrollment. Providers submitting applications for Medicaid enrollment or re-credentialing of an existing enrollment, must send in a completed application packet with all required documentation and information. If the submission is incomplete or incorrect, the provider will be notified by letter that the application was not accepted due to missing and or incorrect documentation or information and the application will be discarded. Medicaid will consider a new application if the provider submits a completed application packet that includes all required documentation and information.
The following provisions are part of every Provider Agreement, whether included verbatim or specifically incorporated by reference:
The Division of Integrated Healthcare may refuse to grant provider privileges to anyone who has been convicted of a criminal offense relating to that person's involvement in any program established under Titles XVIII, XIX, XXI or XX of the Social Security Act, or of a crime of such nature that, in the judgment of the Department, the participation of such provider would compromise the integrity of the Medicaid Program or put the clients at risk. The Division may terminate any provider from further participation in Medicaid if the provider fails to satisfy all applicable criteria for eligibility. Specific rules, including grounds for sanctions and termination, are found in Utah Administrative Code R414-22, and is discussed in Chapter 5, Provider Sanctions.
When providing medical assistance under programs administered by the Utah Department of Health and Human Services, a provider must agree to provide services in accordance with Title VI of the Civil Rights Act as well as other federal provisions which prohibit discrimination based upon race, color, religion, national origin, disability, age, or gender.
A Utah Medicaid provider is under no obligation to accept all Medicaid members who seek care, and may limit the number of members accepted into the provider's practice. However, the limitation may not be based on prohibited discriminatory factors such as race, color, religion, national origin, disability, age, or sex. Restrictions to individual patient care, based upon the limits placed upon provider practice by specialty, and because of medically related determinations made within the scope of practice, are generally permissible. In addition, limitations are generally permissible if applicable to both Medicaid and non-Medicaid clients. Some grounds for denying or dismissing Medicaid clients include limiting the number or percentage of Medicaid clients, missed appointments, abusive behavior, and provider lack of training or experience. Providers may wish to consult their respective state licensing rules for definitions of standards of care for any additional limitations.
A provider should set up established business guidelines that delineate the limitations on accepting Medicaid members, and abide by those guidelines. Exceptions that would allow for accepting Medicaid clients outside the established guidelines would be acceptable as long as those exceptions did not violate the prohibited actions identified in this manual.
Medicaid and MCO
A provider who accepts a member as a Medicaid, Hospital Presumptive, or Baby Your Baby patient must accept the Medicaid or state payment as reimbursement in full. A provider who accepts a member enrolled by Medicaid in an MCO must accept the payment from the plan as reimbursement in full. If a member has both Medicaid and coverage with a responsible third party, do not collect a co-payment that is usually due at the time of service. The provider may not bill the member for services covered by Medicaid, Hospital Presumptive, or Baby Your Baby or by an MCO. The payment received from Medicaid or from an MCO is intended to include any deductible, co-insurance, or co-payment owed by the Medicaid member. In addition, the administrative cost of completing and submitting Medicaid claim forms are considered part of the services provided and cannot be charged to Medicaid members.
Qualified Medicare Beneficiary
Providers who serve Qualified Medicare Beneficiary (QMB) clients must accept the Medicare payment and the Medicaid payment, if any, for co-insurance and deductible as payment in full. Providers may not bill members eligible for the Qualified Medicare Beneficiary Program for any balance remaining after the Medicare payment and the QMB co-insurance and deductible payment from Medicaid. (42 CFR §447.15)
Providers must follow policies and procedures
Providers must follow policies and procedures concerning, but not limited to: medical services covered; medical service limitations; medical services not covered; obtaining prior authorization; claim submission; reimbursement; and provider compliance, as set forth in all Sections of the Utah Medicaid Provider Manual, Medicaid Information Bulletins, and letters to providers. If a provider does not follow the policies and procedures, the provider may not seek payment from the member for services not reimbursed by Medicaid. This includes services that may have been covered if the provider had requested and obtained prior authorization.
There are certain circumstances in which a provider may bill a Medicaid member. They are: non-covered services, spenddown medical claims, Medicaid cost sharing (co-payments and co-insurance), and broken appointments. The specific policy for each item must be followed before the Medicaid member can be billed. Refer also to Chapter 7, Member Responsibilities.
Before collecting a co-payment, confirm the service requires a co-payment and that the member has a co-payment requirement. Give the member a receipt for the co-payment collected. The member is responsible to keep co-payment receipts in case of delayed billings by providers or discrepancies. If a co-payment is not collected at the time of service, the provider may bill the client for it.
A non-covered service is a service not covered by a third party, including Medicaid. Since the service is not covered, a provider may bill a Medicaid member when the following conditions are met:
Unless all conditions are met, the provider may not bill the member for the non-covered service. Further, the member's Medicaid Member Card may not be held by the provider as guarantee of payment by the member, nor may any other restrictions be placed upon the member.
Some members are responsible for “spenddown” payments to qualify for medical services. The member may pay the spenddown amount to the DWS or may pay a medical bill and use this expense to offset their spenddown.
When rendering services to a member with a spenddown, the provider submits a claim to Medicaid for the full amount; do not submit a partial charge. If the member, as part of the spenddown, owes the full amount, the provider may choose not to bill Medicaid.
Medicaid bases reimbursement on the total claim, or on the standard reimbursement, whichever is less. Medicaid deducts the client’s obligation from the Medicaid reimbursement. The remainder is paid to the provider. Therefore, if the provider submits a partial charge (the total less the spenddown amount), the Medicaid reimbursement amount may be less than the actual amount owed to the provider. When the member’s obligation to pay is equal to or more than the Medicaid reimbursement amount, the Medicaid payment is zero.
Information concerning a member's spenddown requirement, if any, is available at AccessNow, 1(800) 662-9651, and the Eligibility Lookup Tool, https://medicaid.utah.gov/eligibility.
A broken appointment is not a service covered by Medicaid. Since the charge is not covered, a provider may bill a Medicaid member only when three conditions are met:
The PCP, which includes physician, NPs, or PAs, may make any referral in writing or verbally. However, the member's medical record must indicate that a referral or consultation was requested.
The consulting physician is responsible for sending the PCP a letter describing the consult findings and a summary of the recommendations.
Providers who make referrals to another provider should consider that Medicaid limits medical transportation to the nearest provider or the nearest appropriate facility which can provide the needed services. Therefore, if the member must use medical transportation covered by Medicaid, the referral must be to the nearest provider or the nearest appropriate facility which can provide the needed services. This limitation includes all medical transportation, in both emergency and non-emergency situations.
Both the referring provider and the servicing/consulting physician are responsible for documenting the consultation or referral written or verbal request. When Medicaid conducts a post-payment review, all of the following information must be in the member’s records to document the referral:
Follow the CMS-1500 (08/05) instructions for entering the referring provider’s number on the claim form. If it is an EPSDT Well Child follow-up referral, enter TS in the modifier field.
Follow the Implementation Guides for entering the referring provider’s identifier/number on the electronic claim. If the visit is an EPSDT Well Child follow-up referral, enter TS in the modifier field.
A physician or immediate family member of the physician who has a financial interest in a health service or item is prohibited from making referrals to those services when payment would be made as a result. Services or items include physical therapy services, occupational therapy services, radiology, MRI and other advanced imaging services, durable medical equipment and supplies, parenteral and enteral nutrients, equipment and supplies, prosthetics, orthotics, home health services, prescription drugs, inpatient and outpatient hospital services, and free-standing surgical centers, etc. The health service may not send a bill to an individual or file a claim with a third party for services provided as a result of such a referral.
A financial interest may be through ownership, or through a direct investment interest (such as holding equity or debt), or through another investment which has ownership or an investment interest in the health service. Penalties include denial of payment for the services provided, payment of civil penalties, and exclusion from participation in the Medicaid program.
A Medicaid provider who accepts a Medicaid member for treatment accepts the responsibility to ensure the member receives all medically necessary services. A definition of medical necessity is provided in this manual in Chapter 1, Definitions and Chapter 8, Programs and Coverage. A provider’s responsibilities include verifying program coverage; referring a member to other Medicaid providers; ensuring ancillary services are also delivered by a Medicaid provider; and ensuring the member receives all covered medically necessary services at no cost.
It is the responsibility of the provider to review Medicaid coverage policy for the procedure or service and request prior authorization (PA) or submit documentation for manual review as noted in the Coverage and Reimbursement Code Lookup tool. The ordering provider must provide the medical record documentation of medical necessity to ancillary providers such as the laboratory or radiology when requested so the ancillary provider may obtain the prior authorization or provide documentation to Medicaid for medical review of the service.
Medicaid providers are required to provide foreign language interpreters for Medicaid members who have limited English proficiency. Members are entitled to an interpreter to assist in making appointments for qualified procedures and during visits. Providers must notify members that interpretive services are available at no cost. Medicaid suggests providers encourage members to use professional services rather than relying on a family member or friend, though the final choice is theirs. Using an interpretive service provider ensures confidentiality as well as the quality of language translation.
If medical interpretative services are needed for a service covered by an MCO, the member is responsible for contacting the plan to obtain an interpreter. The MCO is required to provide interpretive services to the MCO’s enrollees consistent with Medicaid policy.
Medicaid will cover the cost of an interpreter when three conditions are met.
If the three conditions of coverage are not met, the provider may be responsible for the cost of interpretive services. The provider may not bill the member for the service except under the conditions stated in Chapter 3, Provider Participation and Requirements.
Medicaid offers a “Guide to Medical Interpretive Services.” The guide lists member eligibility requirements, contractors, languages offered, and information required from the provider. The guide is available in General Attachments on the Medicaid website at https://medicaid.utah.gov.
The Utah Department of Health and Human Services, Division of Integrated Healthcare, follows the provisions of the Government Records Access and Management Act (GRAMA) in classifying records and releasing information.
Medicaid providers must comply with all disclosure requirements in 42 CFR §455, Subpart B, such as those concerning practice ownership and control, business transactions, and persons convicted of fraud or other crimes. A provider must also disclose fully to Utah Medicaid information about the services furnished to Medicaid members, as circumstances may warrant.
Every provider must comply with the following rules regarding records:
Providers must safeguard members’ privacy and confidentiality, as required by all applicable state and federal laws. The use and disclosure of individually identifiable information or protected health information must be consistent with HIPAA. In accordance with HIPAA, HITECH, and the Government Records Access and Management Act (GRAMA), any information gained from member records is classified as controlled and must be protected pursuant to the guidelines established by law in order to protect the privacy rights of the members.
Any information received from providers is classified as private and will be protected pursuant to the guidelines established by law in order to protect the privacy rights of providers. Records and information acquired in the administration of any part of the Social Security Act are confidential and may be disclosed only under the conditions prescribed in rules and regulations of the Department of Health and Human Services, or on the express authorization of the Secretary of the Department of Health and Human Services.
A Medicaid provider may disclose records or information acquired under the Medicaid Program only under conditions prescribed in the rules and regulations of HIPAA, HITECH, and GRAMA.
The DIH may request records that support provider claims for payment under programs funded through the DIH. Responses to requests must be returned within 30 days of the date of the request and must include the complete record of all services for which reimbursement is claimed and all supporting services. If there is no response within the 30-day period, or a provider cannot provide adequate records for reimbursed services, the services will be deemed undocumented. The Department will recover all payments for undocumented services.
A provider who receives a request from Medicaid for access to or inspection of documents and records must comply with free access to the records and facility. A provider may not obstruct any audit or investigation, including the relevant questioning of employees of the provider.
Repeated refusal to provide or grant access to the records as described above will result in the termination of the Medicaid provider agreement.
To support its mission to provide access to quality, cost-effective health care for eligible Utahans, the Division of Integrated Healthcare requires providers to meet the Evaluation and Management Documentation Guidelines developed jointly by the American Medical Association and the Centers for Medicare and Medicaid Services. Documentation requirements are as follows:
General Principles of Medical Record Documentation in the Evaluation and Management Documentation Guidelines:
In keeping with the objectives of 42 CFR §456 Subpart B (to review and evaluate utilization, service, exceptions, quality of care, and to promote accuracy and accountability), providers and the service they provide must be clearly recognized by name and specialty. Any professional providing service and entering documentation in the member record must include a verifiable, legible signature and professional specialty designation following all entries.
In order for a signature to be valid, the following criteria are used:
All signatures need to be dated; however, when requested Medicaid must be able to determine on which date the service was performed or ordered. If the entry immediately above or below the entry is dated, Medicaid may reasonably assume the date of the entry in question.
Providers should not add late signatures to the medical record, other than those that result from the short delay that occurs during the transcription process. Providers should use the signature attestation process. Medicaid does not accept retrospective orders.
If a clinical diagnostic test order does not require a signature, regulations state there must be medical documentation by the treating physician (e.g., a progress note) that he/she intended the clinical diagnostic test be performed. This must also be authenticated by the author via a handwritten or electronic signature.
Illegible signatures should be accompanied by a typed/printed name on the documentation. If requested by Medicaid, providers may submit a signature log or attestation to support the identity of the signer. However, Medicaid will look for some indication in other documentation to support the identity of the signer.
A signature log is a typed listing of provider names followed by a handwritten signature. A signature log may be used to establish signature legibility as needed throughout the medical record documentation. Providers should include their professional credentials/titles on the signature log, illegible signatures will be processed more quickly than those that do not have a signature log provided.
Providers must have a system and software products that maintain an auditable signature record, protect against modification, and have administrative procedures that correspond to recognized standards and laws.
The individual whose name is on the electronic signature and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided.
• Chart 'Accepted By' with provider's name
• 'Electronically signed by' with provider's name
• 'Verified by' with provider's name
• 'Reviewed by' with provider's name
• 'Released by' with provider's name
• 'Signed by' with provider's name
• 'Signed before import by' with provider's name
• 'Signed: John Smith, M.D.' with provider's name
• Digitalized signature: Handwritten and scanned into the computer
• 'This is an electronically verified report by John Smith, M.D.'
• 'Authenticated by John Smith, M.D.'
Note: 'Signed but not read' is not acceptable
A provider's failure to comply with medical standards, federal audit, quality assurance review, or prior authorization requirements may be determined in the course of manual claim review. Coding errors are often discussed with billers either in the course of manual review or through the pre-hearing process.
Either the Division of Integrated Healthcare or the provider may request a pre-hearing or peer review of the reimbursement determination. A written request by either the Division or the provider for a pre-hearing review must be made within 30 days following the date of the original notice to the provider of the determination of noncompliance. The written request from the provider must be submitted to:
Office of Administrative Hearings
Division of Integrated Healthcare
PO Box 143105
Salt Lake City, UT 84114-3105
Or via UPS or FedEx
Office of Administrative Hearings
Division of Integrated Healthcare
288 North 1460 West
Salt Lake City, UT 84116-3231
In situations of violations of compliance of professionally recognized medical standards, as identified by peer review, the Division of Integrated Healthcare may pursue any legal sanction for recovery of overpayments.
If the provider is found at fault, and Federal Financial Participation is disallowed on reimbursements made to the provider, the provider must reimburse to the State the total amount the State paid for the services disallowed. When manual review documentation suggests attempts to circumvent prior authorization or coverage policy, a case may be referred to the OIG for review. (Refer to Chapter 5, Provider Sanctions.)
Sanctions, which include termination or suspension from participation in the Medicaid program, may be imposed against a provider for conduct such as fraudulent billing practices, failure to keep records to substantiate services to members, failure to repay unauthorized funds, and conviction of certain criminal offenses. Prospective providers may also be excluded from the Medicaid program on certain grounds, such as fraud or current license limitation imposed by the Division of Professional and Occupational Licensing (DOPL) or another state’s licensing board. Before a sanction may be imposed, a provider must be notified of the pending sanction and of his hearing rights. Utah Administrative Code R414-22, Administrative Sanction Procedures and Regulations, provides a more complete description of grounds for sanctions, and administrative sanctions that may be taken against providers.
The Department may suspend or terminate from Medicaid participation any medical practitioner or other health care professional licensed under state law who is convicted of Medicaid or Medicare related crime(s) in either a federal or state court.
When a practitioner or other health care professional is convicted and sentenced in a state court of Medicaid-related crime(s), the Department notifies the Office of Inspector General. (Refer to Chapter 5, Provider Sanctions.)
The Department may request a waiver of suspension or termination if the sanction is expected to have a substantial negative impact on the availability of medical care in the community or area. The waiver request should contain a brief statement outlining the problem, and be submitted to the Centers for Medicare and Medicaid Services (CMS). CMS will notify the Department if and when it waives the sanction. Waivers should only occur if:
Federal Fraud and Abuse regulations adopted by Health and Human Services, Office of Inspector General, provide for significant civil and criminal actions that may be taken against Medicaid providers who employ federally sanctioned individuals. This is true even if the sanctioned individual does not work directly in providing services to individuals under the Medicaid program.
Providers need to be aware that it is their responsibility to verify that the individual is not on a federal sanctions list. Thus, it is essential that providers regularly check (i.e., monthly) the federal sanctions list, which is at https://exclusions.oig.hhs.gov/. If a provider employs an individual who is on the federal sanctions list, and that person provides services which are directly or indirectly reimbursed by a federally funded program, the employer may be subject to legal action which could include civil penalties, criminal prosecution and exclusion from program participation.
It is essential that providers regularly check the federal sanctions list which can be found at the website listed above. It would be advisable for all providers to check current and potential employees against the list on the federal database to ensure that no sanctioned individuals are working for their organization.
Federal regulations require the implementation of a statewide surveillance and utilization control program that safeguards against excessive Medicaid payments, and unnecessary or inappropriate utilization of care and services.
The Utah Office of Inspector General (UOIG) for Medicaid Services, and the Medicaid Fraud Control Unit, Office of Attorney General, address issues related to fraud, utilization control, audits, and investigations. These programs work to ensure Utah’s Medicaid program are in compliance with applicable state and federal law. These offices may receive complaints and referrals from Medicaid recipients, the public, providers, or federal and state agencies. Medicaid fraud is a crime which may result in criminal charges and possibly conviction, incarceration, fines, penalties and also exclusion from the Medicaid and Medicare programs. What constitutes fraud is defined by statute under the False Claims Act found at Utah Code Ann. 26-20-1, et. seq. (Refer to, http://le.utah.gov/xcode/Title26/Chapter20/26-20.html). Some examples of fraud include, but are not limited to, the knowing or intentional act of billing Medicaid for services that were not rendered, including billing for items or materials that were not delivered. Fraud also includes the making of a materially false statement or representation in connection with any claim for payment to the Medicaid program. Providers are also prohibited from accepting illegal kickbacks or bribes for referrals or services, and are also prohibited from billing for services that are medically unnecessary or charging for those services at a rate higher than those charged by the provider to the general public. It is important that you familiarize yourself with the False Claims Act, or contact the Utah Office of Inspector General for Medicaid Services or the Utah Medicaid Fraud Control Unit if you have questions or concerns.
Contact Information for Complaints and Reporting Fraud, Waste and Abuse
Director, Medicaid Fraud Control Unit
Office of the Attorney General
Medicaid Fraud Control Unit
5272 South College Drive, Suite 300
Murray, Utah 84123
(801) 281-1259
Utah Office of Inspector General for Medicaid Services
288 North 1460 West
PO Box 143103
Salt Lake City, Utah 84114
(801) 538-6087, 1(855) 403-7283
https://oig.utah.gov/
A provider or member may request an administrative hearing to dispute an action taken by the Division of Integrated Healthcare (DIH) or an MCO. Actions taken that may be appealed include, but are not limited to:
With respect to denials issued by an MCO, providers or members must complete the MCO’s appeal process prior to requesting a hearing with DIH.
To request a hearing, send a completed hearing request form to the Office of Administrative Hearings. The form must be faxed or postmarked within 30 calendar days from the date DIH or the MCO sends written notice of its denial or intended action, unless a different time period is indicated on the denial document. Failure to submit a timely request for a hearing constitutes a waiver of the due process right to a hearing. The agency is not required to grant a hearing if the sole issue is a federal or state law requiring an automatic change. Utah Administrative Code R410-14 et seq. sets forth the administrative hearing procedures for Medicaid hearings.
A Request for Hearing/Agency Action form (Hearing Request) is available on the Utah Medicaid website at: https://medicaid.utah.gov/utah-medicaid-forms, Hearing Request, or a copy may be requested from the Office of Administrative Hearings by calling (801) 538-6576.
Submit the form by mail or fax.
Mail:
Division of Integrated Healthcare
Office of Administrative Hearings
Box 143105
Salt Lake City, UT 84114-3105
FAX: (801) 536-0143
A Medicaid member is required to present the Medicaid Member Card before each service, and every provider must verify each member’s eligibility each time before rendering services. Presentation of the Medicaid Member Card does not guarantee a member continues eligible for Medicaid. Verify the member’s eligibility, and determine whether the member is enrolled in an MCO, Emergency Only Program, or the Restriction Program; assigned to a PCP; covered by a third party; or responsible for a co-payment or co-insurance. Eligibility and health plan enrollment may change from month to month. Retain documentation of the verified eligibility for billing purposes.
Verify member eligibility using AccessNow, Eligibility Lookup Tool, and ANSI 270 and ANSI 271. Brief descriptions of each are below; for detailed information, call Medicaid Information, or go to the Medicaid website at https://medicaid.utah.gov/medicaid-online.
Note: Medicaid staff makes every effort to provide complete and accurate information on all inquiries. However, federal regulations do not allow a claim payment even if the information given to a provider by Medicaid staff was incorrect.
These tools may be used to verify member eligibility:
Eligibility Lookup Tool
The eligibility lookup tool allows providers to electronically view a member’s Medicaid eligibility and plan enrollment information. To use this tool a provider must register with the State of Utah Master Directory (UMD), available at https://medicaid.utah.gov/eligibility.
AccessNow
Is a touch-tone telephone eligibility line and is a free information system for Medicaid providers. AccessNow allows the provider to access information directly. AccessNow is available Monday through Saturday from 6:00 a.m. to midnight, and Sunday from noon to midnight. There is no limit to the number of inquiries a provider may make. Call Medicaid Information ((801) 538-6155) and follow the menu instructions to reach AccessNow (Chapter 1, General Information).
ANSI 270 and ANSI 271
These two HIPAA compliant transactions offer member eligibility and claim status for providers who are members of the Utah health Information Network (UHIN).
Medicaid members who need confirmation of coverage may call Medicaid Information (Refer to Chapter 1, General information) or access the member Benefit Lookup Tool at https://medicaid.utah.gov.
The Interim Verification of Eligibility (Form 695) is a temporary proof of eligibility. Form 695 is issued when a member needs proof of eligibility and does not yet have a Medicaid Member Card. When a temporary proof of eligibility expires, Medicaid will no longer pay claims, unless the member has since been issued a ten-digit Medicaid identification number.
Information on third party coverage should be verified. Note that some members of a family may have third party coverage, while others may have no coverage or different coverage.
If third party liability (TPL) information is incorrect, advise the member to call the TPL unit in the Office of Recovery Services at the Department of Human Services at (801) 536-8798. Providers may also call the TPL unit about incorrect information. TPL information is corrected by the Office of Recovery Services. In the Salt Lake area, call (801) 741-7437.
Medicaid policy states the provider must pursue payment from all other liable parties such as insurance coverage. Refer to Chapter 11, Billing Medicaid, for information on billing the TPL.
Providers who accept a member covered by Medicaid are asked to ensure that any ancillary services provided to the member are delivered by a participating Medicaid provider. This includes lab, x-ray, and anesthesiology services. Give all ancillary providers a copy of the member’s Medicaid Member Card or, at minimum, the Medicaid identification number. In addition, when the service requires prior authorization (PA) and a PA number is obtained from Medicaid; give the PA number to any other provider rendering service to the member. This will assist other providers who may be required to submit the prior authorization number when billing Medicaid.
A provider should ask for the member's Medicaid Member Card and a picture ID prior to each service to assure the individual presenting the card is the same person on the Medicaid Member Card. Medicaid is a benefit only to eligible persons. Possession of a Medicaid Member Card does not ensure the person presenting the card is eligible for Medicaid.
Members are responsible for providing complete and accurate information to establish eligibility, providing information about all other health insurance, paying co-payment amounts at the time of service, and cooperating with the PCP to receive medical services.
A Medicaid member is responsible for certain charges, including:
The Medicaid program may require certain members to pay for services or benefits, referred to as cost sharing. Cost sharing amounts may include such items as premiums, deductibles, co-insurance, or co-payments.
Refer to Utah State Plan Attachments 4.18-A through H, for additional cost sharing information.
Except for the cost sharing responsibilities discussed above, members are not responsible for the following charges:
This chapter covers services available under the Utah State Medicaid Plan. Services are reimbursed either directly by Medicaid or by a Managed Care Organization (MCO) with which Medicaid contracts to provide the covered services. When the Medicaid member has a PCP, this provider must provide an appropriate referral for medical services received from any other provider (Refer to Chapter 3, Provider Participation and Requirements.)
Covered services are limited by federal guidelines as set forth under Title XIX of the federal Social Security Act, Title 42 of the Code of Federal Regulations (CFR), and the Utah Administrative Code, Rule R414-1-5, Services Available.
Utah Medicaid pays for medically necessary, covered health services, as well as certain services, available by special waiver, provided to eligible members by Medicaid providers. The fact that a provider prescribes, recommends, or approves medical care does not in itself make the care medically necessary or a covered service. Certain services are covered only for specific categories of eligible members. All covered services, both traditional and special services, must be medically necessary, may be limited in scope (i.e., specific number of units of services), and may be subject to prior authorization. Refer to the applicable Section 2 provider manual for specific provider policy and billing instructions and to the Coverage and Reimbursement Code Lookup Tool for covered services [http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php].
Medicaid may exceed the limitations on covered services under certain circumstances. Some services may be provided if Medicaid staff determine, through the utilization review process, the proposed services are medically appropriate and more cost effective than alternative services.
A provider must only furnish or prescribe medical services to the member that are medically necessary. A service is "medically necessary" if it is reasonably calculated to prevent, diagnose, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, or threaten to cause a disability, and there is no other equally effective course of treatment available or suitable for the member requesting the service which is more conservative or substantially less costly. Medical services will be of a quality that meets professionally recognized standards of health care, and will be substantiated by records including evidence of such medical necessity and quality. Those records will be made available to the Medicaid upon request. Medicaid reserves the right to make the final determination of medical necessity.
Services or procedures considered experimental or investigational are not considered medically necessary and thus are not covered by Medicaid. (Refer to Chapter 9, Non-Covered Services and Limitations, Experimental, Investigational, or Unproven Medical Practices). This policy does not apply to members participating in qualifying clinical trials for the prevention, detection, or treatment of any serious or life-threatening disease or condition as outlined in Section 210 of the "Consolidated Appropriations Act, 2021."
To qualify for a Medicaid program, an individual must fit into a specific category and within that category, meet certain citizenship and income criteria (some programs also have a resource or asset test). Some categories and programs provide a full range of medical benefits, while others may offer limited benefits or may require cost sharing by a member. If an individual has income over the limit ("excess income"), he may be asked to spend the excess on medical care or “spenddown” to the Medicaid income level to qualify for the Medicaid Medically Needy Program. Refer to the Medicaid website https://medicaid.utah.gov/ for program details.
The categories of Medicaid:
An individual who is below the asset limit and has monthly income which exceeds the monthly income standard, but less than the amount needed to pay his or her medical bills, may be considered for the Medicaid Medically Needy Program. The program, also known as the “spend down" program, requires the individual to “spend down” his income to the Medicaid income level. The individual may choose to either pay the “excess” monthly income to the state (by sending a payment to DWS), or to pay a portion of his monthly medical bills directly to the medical provider. Pursuant to federal law, Medicaid cannot accept spenddown payments when the source is from a Medicaid provider’s own funds, or if a Medicaid provider has loaned the money to the individual.
There are three Medicare cost-sharing programs for people with Part A Medicare: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary program (SLMB), and Qualified Individual program (QI). While these are not Medicaid programs, they help cover some of the member’s costs for Medicare services. For further information refer to https://medicaid.utah.gov/, Medicare Cost-Sharing Programs.
The eligibility worker may approve Medicaid coverage for a beneficiary for the three months prior to application date. This is called the retroactive period. Coverage can begin as early as the first day of the third prior month. For example: The application date is April 15, this coverage may begin January 1.
The Breast and Cervical Cancer Prevention and Treatment Act allows states to provide full Medicaid benefits to qualified individuals in need of treatment for breast and cervical cancers, including precancerous conditions and early stage cancer. The Utah Cancer Control Program (UCCP) refers the individuals for Medicaid coverage.
To qualify the individual must meet all of the following requirements:
For more information, call the Utah Department of Health and Human Services, Utah Cancer Control Program: (801) 538- 6157 or 1(800) 717-1811. Please have the member’s complete name and telephone number(s).
The Baby Your Baby presumptive eligibility program covers outpatient, pregnancy-related, Medicaid covered services for eligible pregnant women prior to establishing eligibility for ongoing Medicaid. Pregnant women apply for this program through a qualified health provider, usually a community health center or public health department. Inpatient hospital services, and labor and delivery are not covered benefits during the Baby Your Baby presumptive eligibility period.
Members eligible for the Baby Your Baby program are given a ‘Presumptive Eligibility Receipt’ to show they are approved for coverage. A Medicaid Member Card is mailed to the member within a few days of eligibility determination. The member card is used to verify the member’s eligibility. Do not collect a co-payment from a member eligible for the Baby Your Baby Program; a co-payment is not assessed by Medicaid. For more information about application, eligibility, and covered or non-covered services under this program, call the Baby Your Baby Hotline, 1(800) 826-9662.
Note: A newborn infant is not covered when the mother is eligible only for the Baby Your Baby Program. A Medicaid application must be submitted on behalf of the child if assistance is needed in paying the child’s medical bills.
The Hospital Presumptive Eligibility Program (HPE) provides temporary fee-for-service Medicaid coverage for qualified low-income individuals prior to establishing eligibility for ongoing Medicaid. Members apply for this program through a qualified hospital provider.
There are different subprograms under HPE: Child Medicaid 0-5 or Child Medicaid 6-18, Parent/Caretaker Relative, Pregnant Woman, and Former Foster Care Individuals. HPE has the same coverage benefits as Medicaid, and the same prior authorization requirements apply, when provided by any Utah Medicaid provider, with one exception. The Pregnant Woman subprogram under HPE covers only outpatient, pregnancy-related, Medicaid covered services like BYB. Under the Pregnant Woman subprogram, inpatient hospital services, and labor and delivery are not covered benefits during the presumptive eligibility period. In addition, the Pregnant Woman subprogram does not cover charges for services for a newborn infant. (Refer to "Baby Your Baby")
Similar to BYB presumptive eligibility program, members eligible for the Hospital Presumptive Eligibility Program are given a ‘Presumptive Eligibility Receipt’ to show they are approved for coverage. A Medicaid Member Card is mailed to the member within a few days of eligibility determination.
Non-Traditional Medicaid (NTM) provides a scope of service similar to that currently covered by the Utah Medicaid State Plan (i.e., Traditional Medicaid) but with some additional limitations or reduced benefits. Authorization of Non-Traditional Medicaid is by way of waiver approval through the Centers for Medicare and Medicaid Services (CMS) and Section 1115(a) of the Social Security Act.
Providers of NTM services are responsible for complying with all applicable federal and state laws and regulations and Medicaid policy and requirements outlined in the 1115 Waiver, Utah Administrative Code R414-200. Non-Traditional Medicaid Health Plan Services, the Medicaid Provider Agreement, the Medicaid provider manuals, attachments specific to the provider manuals, and the Medicaid Information Bulletins.
Refer to Chapter 6, Member Eligibility, for information about verifying member eligibility, third party liability, ancillary providers, and member identity protection requirements.
The scope of service under NTM is similar to Traditional Medicaid but with some limitations, reduced benefits, and non-covered services.
For specific code coverage and reimbursement information see the Coverage and Reimbursement Code Lookup.
Audiology- Hearing evaluations or assessments for hearing aids are covered. Hearing aids are covered only if hearing loss is congenital.
Emergency Transportation Services- Coverage of ambulance (ground and air) for medical emergencies only. Non-emergency transportation (including bus passes) is not covered.
Medical Supplies and Equipment- Coverage outlined in the Coverage and Reimbursement Code Lookup.
Organ Transplants- The organ transplants covered under NTM include bone marrow, cornea, heart, kidney, liver, lung, and stem cell.
Physical Therapy (PT) and Occupational (OT) Therapy Services- PT and OT are limited to 16 aggregate visits (in any combination) per calendar year.
Vision services- NTM covered services are the same as those for non-pregnant adults. One eye examination is covered every 12-months.
Non-covered services are the same for Traditional Medicaid and NTM members.
The following services are also non-covered for NTM members:
Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program is federally mandated for enrolled Medicaid Members and is an integral part of the Medicaid program. EPSDT services are available to all members enrolled in Traditional Medicaid ages birth through twenty. (Individuals aged 19 through 20 enrolled in Non-Traditional Medicaid do not qualify for EPSDT services.)
This program provides comprehensive and preventive health care services and ensures that children and adolescents receive appropriate preventive, dental, mental health, developmental, and specialty services. Screening services to detect physical and mental conditions are covered at established intervals, including a physical exam, appropriate immunizations, laboratory tests, and health education. In addition, dental, vision and hearing services are available. All medically necessary diagnostic and treatment services within the federal definition of Medicaid is covered, regardless of whether or not such services are otherwise covered for individuals over age 20.
In certain cases, if Medicaid staff determine that the proposed services are both medically necessary and more cost effective than alternative services, then the agency may exceed established limitations on coverage.
There are three major components to EPSDT: Preventive Health Care, Outreach and Education, and Expanded Services. Refer to Section 2, EPSDT Services Provider Manual for details at https://medicaid.utah.gov/utah-medicaid-official-publications.
The Children’s Health Insurance Program (CHIP) is not a Medicaid program but it is a state health insurance plan for children who do not have other insurance. It provides well-child exams, immunizations, doctor visits, hospital, emergency care, prescriptions, hearing and eye exams, mental health services and dental care. Preventative services (well-child visits, immunizations, and dental cleanings) do not require a co-pay. For more information, call 1(877) 543-7669 or visit the CHIP website.
The Custody Medical Care Program pays medical bills for a child placed in the custody of the State and has not yet been determined eligible for Medicaid or is not eligible for Medicaid. The program may pay for services not covered by Medicaid and for services from a provider who may not be a current Medicaid provider.
Medical services are authorized on State Medical Services Reimbursement Agreement Form (MI-706), by the assigned case manager in the Division of Child and Family Services. The case manager gives the foster parent this form, and it must be presented at the time of the medical visit.
Only services identified on the MI-706 form are payable. Every service must be individually authorized before payment is made. Services provided without authorization will not be paid by the Division of Child and Family Services nor by Medicaid. Emergency services may be authorized after the fact, if the service is within the scope of service of the program, and Form MI-706 is obtained before billing. Services must be billed within 365 days of the date of service or six months of the date Form MI-706 was issued, whichever is later. To bill claims, follow the same instructions as for billing Medicaid claims with one exception: every claim requires a prior approval number. (The prior approval number is the MI-706 number.) Medicaid processes the claim, and the payment method and amount is the same as that for the Medicaid Program, even though the child is not eligible for Medicaid.
Medical services for most children placed in state custody are covered by either Medicaid or the Custody Medical Care Program. The State pays medical bills only when the child is eligible for either of these programs. The State does not automatically pay medical bills for children in foster care. Before providing services, determine the child’s health care coverage. Using the available tools found in Chapter 6, Member Eligibility, determine if the child is eligible for Medicaid and assigned to a PCP or ACO.
This information is intended to assist providers in determining and providing health coverage for a child in state custody. Provide services to these children within the time frames outlined in Time Frame for Services below. The Division of Child and Family Services contracts with the Department of Health and Human Services to provide health care case management for children in foster care. Contact the Fostering Healthy Children Program with questions about serving children in state custody.
Children in Foster Care Eligible for Medicaid
Before providing services to children in foster care, check for Medicaid eligibility. Services will not be reimbursed when the child is not eligible for Medicaid, nor when the child is covered by a health plan or Prepaid Mental Health Plan and the provider is not affiliated with the plan. To check eligibility and provider assignment, use the Eligibility Lookup Tool online at https://medicaid.utah.gov/eligibility-lookup-tool or call AccessNow, (801) 538-6155 or 1(800) 662-9651.
Many of the children placed in state custody are already eligible for Medicaid and enrolled in an MCO. As with any other enrollee, these children are covered only for services received from providers affiliated with the MCO(s) identified. The provider receives payment from the child’s MCO. If a child is taken to a provider who is not affiliated with the child’s plan, referred to as “out of plan,” services may not be reimbursed by the plan or by Medicaid.
The child may be enrolled in a Prepaid Mental Health Plan (PMHP) for inpatient psychiatric services only. (Foster care children may obtain outpatient mental health services from any participating Medicaid provider.) The caseworkers in the Division of Child and Family Services are responsible for coordinating any needed outpatient or inpatient mental health services.
For new enrollees, the Division of Child and Family Services (DCFS) chooses an ACO which contracts with the provider(s) the child has seen in the past. Foster parents are trained to use providers affiliated with the health plan and PMHP plans in which the child is enrolled.
When the child is eligible on the date of service and not assigned to a health plan or a PMHP, services may be billed directly to Medicaid as fee-for-service. Some children in state custody come from outside the Wasatch Front (Weber, Davis, Salt Lake, and Utah counties) for medical treatment and are thus not enrolled in a health plan.
Children in Foster Care Not Eligible for Medicaid
When a foster child is not eligible or not yet eligible for Medicaid, the child may qualify for the Custody Medical Care Program (see above Children in Foster Care Eligible for Medicaid). A nurse from the Fostering Healthy Children Program (FHC) may authorize medical services on State Medical Services Reimbursement Agreement Form (MI-706), and give it to the foster parent. (FHC is a program within the Department of Health and Human Services which contracts with the Division of Community and Family Health Services, to provide nurse case manager services). This form must be presented at the time of the visit. Services provided without this authorization will not be paid by DCFS or Medicaid.
Time Frame for Services (Foster Care)
Children removed from their homes must receive certain services within the specific time frames listed below. Providers are encouraged to do everything possible to provide service to the child placed in state custody within the following time frames.
Children must receive
Emergency services for non-citizens are designed to cover a limited scope of services as outlined in 42 CFR 440.255(c). Individuals meeting all Medicaid eligibility requirements except citizenship may receive coverage for a qualifying emergency service as defined in Utah Administrative Code R414-1-2(11) and meeting service coverage criteria outlined in Utah Administrative Code R414-518.
When determining eligibility and coverage related to outpatient hemodialysis, see the “Provider Instructions for EOP Dialysis Coverage.”
Individuals who qualify for these services are issued a Medicaid Member Card. Services require documentation and review before payment to determine the services meet the definition and limitations stated above.
Any payment made by the Medicaid Agency for a service is considered payment in full. Once the payment is made to the provider for covered services, no additional reimbursement can be requested from the member. Because the emergency services program for non-citizens has a very restricted scope of services, it does not have some of the same restrictions on billing the member as is the case in other Medicaid covered services. If a provider does not receive payment from Medicaid because the provider failed to follow procedure to get a service covered, the provider is prohibited from pursuing payment from the member. However, if payment is not made because the service was not an emergency, or the service is not covered under the program, then the member can be billed for those services.
If a service is a covered service and meets the Medicaid definition of “emergency,” Medicaid will pay for the service (subject to correct coding). However, if a non-citizen eligible for emergency services only presents at the ER with symptoms that do not appear to be emergent in nature, the provider would be prudent to inform the member, prior to the service, that the service might not be covered by Medicaid, and in that case the member will be financially responsible for paying the bill.
Billing for services provided to an emergency services only program member:
FAX to:
Emergency Services Program for Non-Citizens
(801) 536-0475
(This number is also on the Documentation Submission Form)
The Medicaid billing address is in Chapter 1, General Information.
All information to be considered for review MUST be included in the initial submission. A second submission will not be considered for payment, unless additional records
are requested.
All claims are held in queue for 60 days from the date of service prior to undergoing manual review, this allows for receipt of all related documentation and to help assure representation of the full episode of care.
The Medicaid Restriction Program safeguards against inappropriate and excessive use of Medicaid services. If a Medicaid member utilizes pharmacy services, emergency department or provider services at a frequency or amount that is not medically necessary, that individual may be referred to and enrolled in the Restriction Program. Members enrolled in the Restriction Program are assigned to one PCP to oversee the member’s healthcare and one Primary Pharmacy.
Members are identified for the Restriction Program through on-going surveillance of member profiles to detect excessive use of services and by referral from providers, pharmacies, law enforcement, citizens etc. Medicaid members enrolled in an ACO and Fee-for-Service members can be enrolled in the Restriction Program. Restricted ACO members are managed by the ACO’s Restriction Program, while restricted Fee-for-Service members are managed by the Department of Health and Human Services (DHHS) Medicaid Restriction Program.
If it is suspected that a Medicaid member is over-utilizing, abusing or fraudulently using Medicaid services, referrals for possible enrollment in the Restriction Program may be submitted to medicaidrestriction@utah.gov or (801) 538-9045 or to the specific ACO Restriction Program in which the member is enrolled, as applicable.
Medicaid members, referred to a Restriction Program or identified by Medicaid surveillance, will be subject to a utilization review for meeting or exceeding the following Restriction criteria during their most recent 12 months of Medicaid eligibility:
Member’s diagnoses, extenuating circumstance and limited access to care (as sometimes seen in rural geographic locations or homelessness) will be taken into consideration during each utilization review. Subsequent to such considerations, members who meet or exceed Restriction Program criteria will be enrolled in the Restriction Program for a minimum of 12 months of Medicaid eligibility.
Restricted members are encouraged to use Urgent Care services when their assigned PCP is not available for immediate medical needs and the need is not emergent. In order for prescriptions written by Urgent Care Providers to be paid, the Urgent Care prescriber’s name and NPI must be added to the member’s case by contacting the ACO or DHHS Medicaid Restriction Program, as applicable. As per federally mandated “Emergency Medical Treatment and Labor Act (EMTALA)”, access to emergent medical services are available to restricted members
Members selected for enrollment in the Restriction Program are notified of the reasons for the enrollment, counseled in the appropriate use of health care services, and offered assistance in selecting a single PCP and a single pharmacy. Prior to assigning a PCP to a restricted member’s case, the PCP must approve of the assignment and agree to manage the restricted member’s healthcare needs.
Assigned PCPs must provide referrals for restricted members in need of specialty or secondary healthcare services. In addition, PCPs must notify the ACO or DHHS Medicaid Restriction Program of the addition of the approved specialty or secondary providers to the member’s restriction case. To submit approval for the additional providers/prescribers to a restricted member’s case, the PCP or PCP’s designee must contact the DHHS Medicaid Restriction Program at (801) 538-9045 or medicaidrestriction@utah.gov for FFS members or by contacting the specific ACO Restriction Program in which the member is enrolled, as applicable.
In making provider and pharmacy assignments, DHHS and the ACOs ensure that the member has reasonable access to healthcare, taking into account geographic location, reasonable travel time to pharmacy services, and adequate quality of necessary healthcare.
Temporary pharmacies may be approved for use by restricted members for good cause such as filling prescriptions for compounded medications; the primary pharmacy is temporarily out of a prescribed medication, hospital discharge medications filled by a hospital pharmacy etc. To request approval for additional temporary pharmacies to be added to the restricted member’s case, members, pharmacies and providers may contact the DHHS Restriction Program at (801) 538-9045 or the specific ACO Restriction Program in which the member is enrolled, as applicable.
Claims will not be paid unless services rendered to restricted members are submitted by the assigned PCP or submitted by other specialty or secondary providers to whom the PCP has provided a referral. Claims submitted for services rendered by specialty or secondary providers to restricted members must note the name and NPI of the referring PCP on the submitted claim in order to be eligible for payment. Claims submitted for specialty services for restricted members with modifiers 23, 25, 30, 47, 55, 56, 62, 75, 66 and 80 are only eligible for payment with a referral from the assigned PCP. Hospital in-patient claims are not subject to the Restriction Program.
Prior to providing services to Medicaid members, all providers are strongly advised to use the available resource of the on-line Eligibility Look-up Tool and telephonic ACCESS NOW in order to identify member’s enrollment in the Restriction Program. These tools will list any approved providers and pharmacies on the restricted member’s case. Providers and pharmacies not listed on a restricted member’s case are not approved for payment by the ACO or DHHS Medicaid Restriction Program.
Medicaid members who are inmates of a public institution (including jail) are not entitled to ongoing Medicaid services. The facility is responsible for all medical expenses incurred during the member’s stay, unless the member becomes an inpatient in a hospital. An inmate may qualify for Medicaid for the inpatient stay days. An inmate must meet eligibility criteria for a Medicaid program.
For information related to the coverage and payment of outpatient drugs, including medications obtained through the 340B program, which are dispensed or administered to Medicaid recipients, refer to the Utah Medicaid Provider Manual for Pharmacy Services at: https://medicaid.utah.gov.
Definitions
Telehealth services means the transmission of health-related services or information through the use of electronic communication or information technology.
Telemedicine is the delivery of medical services and any diagnosis, consultation, treatment, transfer of medical data or education related to health care services using interactive audio or interactive video communication instead of in person contact.
Teledentistry is the use of information technology and telecommunications for dental care, consultation, and education.
Telepsychiatric Consultation is a consultation between a physician and a board-certified psychiatrist that utilizes:
Authorized Provider means a provider in compliance with requirements as specified in this manual, refer to Chapter 3, Provider Participation and Requirements.
Distant site means the physical location of a healthcare provider delivering healthcare services via a telecommunication system.
Originating site means the physical location of the member at the time the service is being furnished via a telecommunication system.
Synchronous interaction means real-time communication through interactive technology that enables a provider at a distant site and a member at an originating site to interact simultaneously through two-way audio or video transmission.
Utah Medicaid covers medically necessary, non-experimental, and cost-effective services provided via telehealth. There are no geographic restrictions for telehealth services.
Reporting requirements for services provided via telehealth are the same as those provided when the member is present (in-person). Examples of covered telehealth services include but are not limited to the following:
It is acceptable to use telehealth to facilitate contact directly between a member and a provider. For example, services are provided between a member and a distant site provider when they are in their home or another location. Additionally, the distant site provider may participate in the telehealth interaction from any appropriate location.
Providers may submit claims for procedure codes that they are already eligible to report.
As described in Utah Code 26-18-13.5, telepsychiatric consultations between physicians and board-certified psychiatrists are covered services.
Psychiatrists must report the following time-based CPT codes:
The requesting physician must report CPT code 99358.
This service will be covered by all Managed Care Entities (MCE). If a member receiving the service is part of an MCE, the provider must be enrolled with the member's MCE to receive reimbursement.
Teledentistry services are covered for eligible members statewide. Providers must bill the appropriate teledentistry code D9995- Teledentistry synchronous on a line in addition to one of the three associated dental codes below:
The teledentistry codes will be reimbursed at $0 and will be used for tracking purposes only. Rates for approved teledentistry services are the same as rates for in-person dental services.
Refer to the following when billing for services provided through telehealth:
Distant providers:
Telehealth encounters must comply with HIPAA privacy and security measures and the Health Information Technology for Economic and Clinical Health Act, Pub. L. No.111-5, 123 Stat. 226, 467, as amended to ensure that all member communications and records, including recordings of telehealth encounters, are secure and remain confidential. The provider is responsible for ensuring the encounter is HIPAA compliant. Security measures for transmission may include password protection, encryption, and other reliable authentication techniques. Compliance with the Utah Health Information Network (UHIN) Standards for Telehealth must be maintained. These standards provide a uniform standard of billing for claims and encounters delivered via telehealth.
Services not otherwise covered by Utah Medicaid are not covered when delivered via telehealth.
The provider at the originating site receives no additional reimbursement for the use of telehealth services.
The following is a high-level list of covered services. More detailed information is described in State Plan Attachments 3.1-A and B and corresponding sections of this manual
Medicaid reimbursement for abortion services is limited to procedures consistent with the Hyde Amendment restrictions. The Hyde Amendment allows for the use of federal funds for abortion procedures to terminate a pregnancy under two conditions:
In addition to the above conditions, Medicaid reimbursement for abortion services is allowed only when:
When circumstances occur that lead to a natural pregnancy loss or inevitable abortion, Medicaid will not reimburse any procedures or misoprostol when fetal heart tones are present. Ultrasound must confirm no fetal heart activity before procedures or misoprostol are initiated or administered.
The following services are not covered by Medicaid regardless of medical necessity. The list is not all-inclusive. Additional non-covered services are described in the Physician Services Section of this manual and other corresponding sections.
Examples:
Note: Experimental, investigational, or unproven services do not include qualifying clinical trials for the prevention, detection, or treatment of any serious or life-threatening disease or condition as outlined in Section 210 of the "Consolidated Appropriations Act, 2021."
The Division of Integrated Healthcare has the authority to limit the amount, duration, or scope of services or to exclude a service or procedure from coverage by Medicaid. Policy recommendations are based on medical necessity, appropriateness, and utilization control concerns [42 CFR §440.230]. Recommendations consider the following:
Medically necessary, scheduled, medical services are furnished out-of-state to Utah Medicaid members in accordance with 42 CFR §431.52. Medical necessity is indicated when the same services or the closest Medicaid providers are not available within the state, or a higher level of expertise is available in another state, or there is no other equally effective course of treatment available or suitable for the patient requesting the service, that is more conservative or substantially less costly. The out-of-state provider must be enrolled or will be enrolled with Utah’s Medicaid program on or before the date of service.
Emergency medical services are reimbursed if the services are a covered Utah Medicaid benefit and if the provider becomes a Utah Medicaid provider.
Medicaid does not reimburse providers for medical, surgical, other health care procedures or treatments, including the use of drugs, biological products, other products, or devices that are considered experimental, investigational, or unproven. See note below.
Some procedures may have research supporting efficacy, but do not yet have a HCPCS code available for billing. Coverage determination recommendation is made through Utilization Review or EPSDT committees on a case by case basis when there is evidence-based efficacy research and documentation of member medical necessity. If coverage is recommended, the case then goes through the administrative approval process before the provider is notified of the final decision.
Note: Experimental, investigational, or unproven services do not include qualifying clinical trials for the prevention, detection, or treatment of any serious or life-threatening disease or condition as outlined in Section 210 of the "Consolidated Appropriations Act, 2021."
A "Qualifying Clinical Trial" is a clinical trial (in any clinical phase of development) that is conducted in relation to the prevention, detection, or treatment of any serious life-threatening disease or condition and is described in any of the following 1 through 3 as defined in the Consolidated Appropriations Act, 2021, as follows:
Generally, Medicaid does not reimburse non-covered procedures. However, exceptions are considered through the utilization review process in the circumstances listed below:
Some services, medical supplies, and durable medical equipment have established quantity limits. Specific quantity limits are indicated on the Coverage and Reimbursement Code Lookup tool. A prior authorization request must be submitted when requesting more than the allowed amount.
The prior authorization request must include proper documentation of medical necessity, specifically why the quantity limit needs to be exceeded, how much is being requested, and over what period of time.
The information in this chapter pertains to prior authorization (PA) requests for Utah Medicaid fee-for-service authorizations only. If the prior authorization request is for a member covered under a Managed Care Organization (MCO), and the service being requested is not a carve-out service, contact the MCO for instructions on requesting prior authorization. Contact information for Managed Care Organizations is found on the Utah Medicaid website at https://medicaid.utah.gov/prior-authorization, Contact Us; scroll to the applicable MCO.
When prior authorization is required for a health care service, the provider must obtain approval from Medicaid before service is rendered to unless the program specific Section of the provider manual states that there are exceptions to obtaining authorization prior to service delivery. Medicaid can pay for services only if all conditions of coverage have been met, including but not limited to, the requirement for prior authorization. Failure to obtain prior authorization may result in a denial of payment. Providers are responsible for determining whether prior authorization is required.
There are exceptions to the requirement for written prior authorization for specific provider types and services; these are noted in the related sections of this manual.
Code specific criteria and instructions are in the Coverage and Reimbursement Lookup Tool at http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.
To obtain prior authorization, the provider must complete a current copy of the appropriate prior authorization request form and submit it, with all required documentation, to the Prior Authorization Unit at the Division of Integrated Healthcare. The appropriate forms are found at https://medicaid.utah.gov/prior-authorization, General PA Forms or Pharmacy Criteria Forms.
When a prior authorization request is submitted without complete documentation, the request is returned without processing. Medicaid returns the request and indicates what additional documentation is required before the request can be reviewed to determine medical necessity. A returned request is not a denial and has not accrued hearing rights. When a prior authorization request is returned for lack of documentation, the provider is required to resubmit the entire request including the additional documentation. Upon receipt of the resubmitted request, Medicaid staff reviews the PA request to determine if the service is covered by Medicaid and if the service is medically necessary. The date in which a complete request, with all necessary supporting documentation, is received will be the date posted for the PA request.
When a prior authorization request is denied, Medicaid sends a written notice of decision to the member, and a copy to the provider. Either or both may appeal the denial.
If Medicaid denies authorization, the letter of denial is sent and includes this information:
Copies of applicable policies, laws, and criteria supporting the decision are included with the letter. A Hearing Request Form with instructions for requesting a hearing is also attached. The denial letter does not include a request for new or additional information.
When a request for a hearing is submitted, Medicaid follows the policy and procedure under Utah Administrative Code, Section R410-14.
FAX Requests:
FAX the PA request to the appropriate number listed on the applicable prior authorization request form.
The prior authorization request forms are found at https://medicaid.utah.gov/prior-authorization, General PA Forms or Pharmacy Criteria Forms.
Mail PA requests to:
Medicaid Prior Authorization Unit
P. O. Box 143111
Salt Lake City, UT 84114-3111
Telephone Submission:
When policy permits, submit a request by calling (801) 538-6155 or 1(800) 662-9651; Select option 3, option 3 and then select the appropriate program.
Medicaid PA unit hours are M, T, W, F, 8:00 a.m. to 5:00 p.m. and Thursday 11:00 a.m. to 5:00 p.m.
Coverage may be available for EPSDT eligible members when a service is not covered by Medicaid for an adult. For complete information concerning prior authorization for EPSDT eligible members, refer to the applicable Section 2 of the Utah Medicaid Provider Manual: EPSDT Services and Autism Spectrum Disorder Related Services for EPSDT Eligible Individuals.
Prior authorization requests for EPSDT services must be in writing and include all applicable information listed below:
All providers involved in the diagnosis, evaluation or treatment of the patient, should communicate directly and work together as a team to evaluate the most appropriate services for the child.
When providers have delivered a service requiring prior authorization without having obtained prior authorization, Medicaid allows requests for retroactive approval under limited circumstances outlined in this chapter. If the criteria are not met, Medicaid will not consider retroactive authorization and the claim will be denied.
In addition to the criteria outlined throughout this chapter, services provided must meet all Medicaid criteria for coverage and providers must:
A provider must request retroactive authorization within 180 days following delivery of services, or Medicaid will deny coverage of the services.
Providers should request authorization, whenever possible, prior to the service being rendered. Refer to the program-specific Utah Medicaid provider manuals for documentation and criteria requirements of the requested service.
If a provider demonstrates that a Medicaid representative or Medicaid's website gave inaccurate information about the need for prior authorization, a retroactive authorization may be requested.
Providers must submit supporting documentation of inaccurate information in writing via email, fax, or mail. The documentation must include corroborating information such as the customer service representative's name with the date and time of the phone call, or screenshots from the website with a timestamp, etc.
There are circumstances in which an individual's eligibility and enrollment with Medicaid have yet to be determined. Upon verification of Medicaid eligibility, a provider may request retroactive approval of services that require prior authorization. Refer to Chapter 8-2.3, Retroactive Eligibility, for additional information. Medicaid eligibility verification, including retroactive eligibility, is the provider's responsibility.
Once member eligibility has been determined, a provider may submit a retroactive authorization request for services rendered during the retroactive period.
Services performed during a medical emergency, that require prior authorization, are eligible for retroactive authorization including medical supplies and durable medical equipment. Documentation must support emergent and medical necessity criteria as well as any other Medicaid coverage criteria.
Certain medical supplies and equipment that require prior authorization may be provided in a medical emergency before authorization is obtained from Medicaid. When a medical emergency occurs, Medicaid may consider the request for retroactive authorization and payment.
It is the responsibility of the medical supplier to substantiate the emergency and provide the necessary documentation to support a prepayment review.
Providers must obtain prior authorization for all other services, supplies, and equipment, even if the member’s circumstances appear to qualify as an emergency.
Examples of medical supplies that may meet this condition: hospital bed, oxygen and related equipment. Refer to Medical Supplies Provider Manual, Section 2, for details.
If, during a surgical procedure, a physician determines that an additional or different procedure is medically necessary, and if the service meets all Medicaid criteria for coverage but requires prior authorization, the service is eligible for retroactive authorization. The provider must provide documentation supporting the change in the planned procedure.
When a surgical procedure requires prior authorization, the associated anesthesia codes are typically prior authorized as a component of the procedure.
When a surgical procedure does not require prior authorization, but the associated anesthesia code does, the anesthesia code, in this instance, does not require prior authorization.
When a surgical procedure requires prior authorization and the surgeon fails to obtain prior authorization, retroactive authorization may be approved when all required documentation is submitted and upon confirmation that the surgery was not:
Inmates are not eligible for Medicaid while incarcerated. However, the Eligibility Lookup Tool will indicate that the individual is eligible for Medicaid if they were eligible before incarceration. The prior authorization (PA) reviewer will verify admission to an inpatient hospital setting and that they are an inmate before issuing a PA.
Before rendering services that require a PA, acquisition of a PA is not necessary for inmates. Medicaid authorizes requests retroactively when services are deemed medically necessary and documentation meets Medicaid policy requirements.
Providers must include the following as part of their retroactive prior authorization request:
Due to considerable variances in Medicare and Medicaid coverage policies, retroactive authorization for durable medical equipment, medical supplies, prosthetics, or orthotics may qualify for retroactive authorization of services.
Medicaid does not make exceptions for retroactive authorization for Medicare Supplement Plans. For additional information regarding dual eligibility, refer to Chapter 11-5.1, Medicare Crossover Claims.
Note: Medicare Crossover claims only apply to Medicare Part A and Part B. No exceptions will be made for Medicare Supplement Plan Coverage.
Providers may request retroactive authorization when quantity limits are inadvertently exceeded. For example, a provider unknowingly exceeds quantity limits for a previously performed service by a different provider. The new provider should make every reasonable effort, such as contacting customer service, to determine if quantity limits have been met.
Each provider is responsible for checking quantity limits and requesting prior authorization once quantity limits are met. Quantity limits are counted toward the member and are not unique to the provider. Additionally, if more than one request is received for the same item or service, authorization for the first complete request will be the one approved.
This exception does not apply to pharmacy claims. For more information, refer to the Pharmacy Services provider manual.
Medicaid delay in prior authorization
When a delay in prior authorization rests with Medicaid, the date of the complete submission for prior authorization is considered. However, the submitted documentation must meet the criteria for approval.
Non-covered services
Generally, Medicaid does not provide reimbursement for non-covered services. However, exceptions may be considered through the prior authorization/utilization review process in the circumstances listed below and when there is no code that is a covered Medicaid benefit that accurately describes the service to be provided:
This chapter covers topics such as billing procedures, third party claims, coding, and manual review.
The provider may bill Medicaid only for services which were medically indicated and necessary for the member and either personally rendered or rendered incident to his professional service by an employee under immediate personal supervision, except as otherwise expressly permitted by Medicaid regulations. The billed charge may not exceed the usual and customary rate billed to the general public, such as individual member accounts or third-party payer accounts.
As required by law, Medicaid is the payer of last resort, meaning that other third parties must be billed before Medicaid can be billed for the service. Medicaid members may have third party coverage of health expenses, such as Medicare, employment-related insurance, private health insurance, long-term care insurance, court judgments, automobile insurance, and so forth. Again, all other resources must be exhausted before Medicaid can consider payment.
The use of any device or strategy that may have the effect of increasing the total amount claimed or paid for any service beyond the maximum allowable amount payable for such service is not allowed. Following are examples of unacceptable billing practices.
A billing or business agent is a person or an entity that submits a claim for a provider and receives Medicaid payments on behalf of a provider. Payments may be made to a business agent, such as a billing service or an accounting firm that furnishes statements and receives payments in the name of a provider, if the agent's compensation for this service meets three conditions: (1) is related to the cost of processing the claim; (2) is not related on a percentage or other basis to the amount that is billed or collected; and (3) is not dependent upon the collection of payment.
As a reminder to all providers, federal regulations prohibit the use of a factor to obtain payment from Medicaid for any service furnished to a Medicaid member. The regulations define a factor as an individual or an organization, such as a collection agency or service bureau, which advances money to a provider for accounts receivable that the provider has assigned, sold, or transferred to the individual organization for an added fee or a deduction of a portion of the accounts receivable. A factor does not include a business representative. Payment for any service furnished to a Medicaid member by a provider may not be made to or through a factor, either directly or by power of attorney. (Services provided under Emergency Only programs are exceptions to this factoring prohibition.)
Medicaid Members who have Medicare: Accepting Members with Dual Coverage
When a Medicaid member also has Medicare, a provider may either accept the member as having dual coverage or not accept either type of coverage. Federal Medicaid regulations do not permit a provider to reject Medicaid and accept only Medicare. For example, when a member has Medicare, a provider cannot bill the member for services that would have been provided under Medicaid, and accept only Medicare payment. A provider can only refuse Medicaid and insist the member must be "private pay" if there is no Medicare coverage. Of course, the Medicaid agency urges that providers accept the patient as a Medicaid member, then follow the procedures outlined in the applicable Sections of the Utah Medicaid Provider Manual for billing TPL.
Medicare/Medicaid Crossover Claims
To ensure prompt processing, the Medicaid provider’s NPI must be on the claim. The deadline for filing a Crossover claim is 365 days from date of service or six months after Medicare disposition. Medicaid may then consider payment of a Medicare deductible and co-insurance, even if the Medicare intermediary or carrier crosses the claim to Medicaid after more than a year has passed since the date of service. Medicaid may also consider such a claim for payment if Medicare notifies only the provider and does not electronically forward the claim to Medicaid.
If the provider accepts assignment for Medicare Part A or Part B, the Crossover claim is sent to Medicaid Crossovers automatically from the intermediary. If the provider does not accept assignment, a claim is not sent automatically, and the provider must submit the claim directly to Medicaid Crossovers.
Payment is reported on the Crossover section of the Medicaid Remittance Statement. The Medicare and Medicaid payment are considered payment in full.
Submit claims directly to Medicaid Crossovers. Instructions are online at https://medicaid.utah.gov/ under Coordination of Benefits.
Non-Covered Medicare Services
Bill claims for non-covered Medicare services, such as non-durable medical supplies, drugs, and Intermediate Care Facility (ICF) nursing home care provided to Medicare/Medicaid eligible members directly to Medicaid.
Submission of Crossover Claims
Paper Claims
Submit to:
Medicaid Crossovers
P.O. Box 143106
Salt Lake City, Utah 84114-3106
Electronic Claims
It is necessary to submit an Explanation of Medicare Benefits (EOMB) for $0 payment or denials. Complete the other payer payment information, including payer paid amount, member liability, and reason codes.
Submit to:
| Utah Medicaid Crossovers | HT000004-005 |
| Fee-for-Service | HT000004-001 |
| Atypical | HT000004-801 |
If third party liability (TPL) information appears to be incorrect (for example, the TPL denies a claim as "patient not eligible"), the provider should advise the member to call the TPL unit in the Office of Recovery Services (ORS) at the Department of Human Services. Providers may also call ORS to advise them of correct third-party liability information.
If a member has both Medicaid and coverage with a responsible third party, do not collect a co-payment that is usually due at the time of service. The provider should include the primary insurance co-payment as part of the submitted charges to Medicaid. A provider must seek and secure payment from all other liable third parties such as insurance coverage, a health plan and Medicare Part A and B. The Medicaid payment is made after all other liable third parties have made payment or sent a denial.
Bill the responsible third party, then Medicaid, as follows:
Medicaid will make an additional payment to a provider for services rendered if the payment received from the insurance company is less than the Medicaid reimbursement amount or
Medicaid will not make an additional payment if the amount received from the insurance company is equal to or greater than the Medicaid reimbursement amount. In this case, the TPL payment is considered payment in full. A provider will not bill the member for any difference between the amount charged and the TPL payment received.
If a provider receives a third-party payment and does not bill Medicaid for the balance because he or she anticipates the Medicaid payment to be zero, the TPL payment is considered payment in full, and the provider may not bill the member.
An exception is inpatient hospital claims with third party insurance. Refer to, Hospital Services of Provider Manual, Section 2.
If the third party denies the claim for any reason (non-covered benefit, patient not eligible, etc.) submit a claim to Medicaid. The claim may be filed electronically, include written documentation on the TPL response. Documentation sent separately goes to ORS. If the third party pays less than reported on the Medicaid claim, submit a replacement claim showing the correct amount received from the TPL.
When a Medicaid claim is suspended for third party liability information, you can expedite the processing of the claim by faxing the complete Explanation of Benefits (EOB) directly to the Health Claims team at ORS. Include the second page which usually has the definitions of coded reasons for not paying the claim.
For claims other than Medicare or TPL use FAX number (801) 536-8513.
For additional guidance on TPL and/or Coordination of Benefits, please visit the following website resource pages: https://medicaid.utah.gov/utah-medicaid-official-publications/ and https://medicaid.utah.gov/hipaa/providers/#companion-guides.
Bill all services for newborns with the baby’s own (unique) Medicaid member number. You may obtain the baby’s Medicaid number by calling Medicaid Information. Refer to Chapter 1, Member Information.
If the baby does not have a unique Medicaid member number, the mother must notify her eligibility worker immediately. The worker determines the child’s eligibility, and a unique Medicaid member number is assigned to the child.
Note: A newborn infant is not covered when his or her mother is eligible only for the Baby Your Baby Program. In this case, the mother must apply for Medicaid on behalf of the child if she needs assistance in paying the child’s medical bills.
Utah Medicaid promotes the use of electronic transactions. Electronic Data Interchange (EDI) is the exchange of health-related information, including claims, electronically. The Medicaid EDI team is available to provide direction, answer questions, and assist providers or billing agents with the submission of electronic transactions. In order to submit claims electronically, providers must complete an EDI application form, which can be found on the Medicaid website at https://medicaid.utah.gov/.
Medicaid utilizes the Utah Health Information Network (UHIN), an internet-based system that can be used to interface between a medical billing system and UHINet (UHIN’s internal portal). It can also be used to directly type in claims, eligibility inquiries, exchange administrative messages (claims, remits, claim attachments). UHIN is the receiving point for Medicaid health care transactions, and transactions sent to Medicaid via UHIN are immediately placed in the MMIS for processing during the next claim cycle. For more information, visit the UHIN website at https://UHIN.org or contact UHIN at (801) 466-7705.
If providers use software other than UHIN, it must be compatible with UHIN and conform to ANSI standards. Your software vendor can advise you as to the systems which use the ANSI standards in compliance with HIPAA and UHIN requirements.
As defined in the Rule R590-164, Medicaid accepts the following paper claims:
Medicaid does not provide instructions for the use of each box on the paper claim forms.
The Utah Insurance Commissioner maintains standards to clearly describe the use of each box (for print images) and its crosswalk to the HIPAA transactions. The Utah standards to describe the use of each box on the Professional Claim CMS-1500 (08/05), the ADA Dental Claim (2006) and the Institutional Claim UB-04 claim forms are available from the UHIN or the insurance commissioner.
NCPDP maintains instructions for the pharmacy claim form at http://www.ncpdp.org/Products/Universal-Claim-Forms
The Point of Sale (POS) system accepts standardized claims for pharmacy services to be submitted through an electronic data exchange. For information about acceptable software for submitting inquiries, transmitting claims, and electronic procedures and messages, refer to Pharmacy Services Provider Manual, Chapter 6 Billing. As electronic data interchange features become available, Medicaid will notify providers in the Medicaid Information Bulletin.
Utah Medicaid follows the HIPAA mandated TCS standards as set forth by DHHS and CMS. Electronic Data Interchange (EDI) is the most efficient method of submitting and receiving large amounts of information within the Utah Medicaid Management Information System (MMIS). Accredited Standards Committee (ASC X12) Implementation Guides are available from the Washington Publishing Company.
Utah Medicaid-specific Companion Guides to the X12 Implementation Guides and National Council of Prescription Drug Programs (NCPDP) payer sheets are available on the Medicaid website at https://medicaid.utah.gov.
Utah Medicaid EDI Help Desk
Telephone 1(800) 662-9651 or (801) 538-6155, option 3, option 5
Mail written correspondence to:
Office of Medicaid Operations
PO Box 143106
Salt Lake City, UT 84114-3106
Federal regulations require that a claim must be submitted to Medicaid within 365 days from the date of service. The date of service, or “from” date on the claim, begins the count for the 365 days to determine timely filing. For institutional claims that include a span of service dates (i.e., a “from” and “end” date on the claim), the “end” date begins the count for the 365 days to determine timely filing. Any adjustments or corrections must also be received within the 365-day time period.
Requesting Review of Claim That Exceeds Billing Deadline
It is to the provider's advantage to submit claims and follow-up on unpaid balances within the billing deadline. Claims received by Medicaid after the billing deadline will be denied. Providers may request to correct a claim outside of the timely filing deadline; however, no additional funds will be reimbursed. Any exception to the 365-day limit is stated below.
Untimely Claims - When Payment Can Be Made
If Medicaid denied a claim for exceeding the billing deadline, the provider may request a review for payment. The situations listed below may be considered for review, provided specific, appropriate documentation is submitted.
Requesting Review for Payment
If the provider has documentation to demonstrate one of the above situations, send the documentation with a copy of the Medicaid remittance and a Document Submission Form, to:
Office of Medicaid Operations
Attn: Timely Filing Review
PO Box 143106
Salt Lake City, Utah 84114-3106
When the documentation is received, the request is reviewed. If Medicaid finds that criterion for one of the timely filing exceptions is met, Medicaid will waive the time limit and initiate processing of the claim.
The definitions of the terms “clean claim” and “new claim” affect which claims and adjustments Medicaid may consider for payment when more than 365 days have passed since the date of service.
Clean claim - Federal regulations define a clean claim as a claim that Medicaid can process without obtaining additional information from the provider of the service or from a third party, including a claim with errors originating in a State’s claim system. A claim that denies for omitted or incorrect date or for missing attachment is not a clean claim. A claim filed more than 365 days after the date of service is not a clean claim.
New claim - A new claim is a claim that is unique, differing from all other claims in at least one material fact. It is important to note that identical claims received by Medicaid on different days differ in the material fact of their receipt date and are both new claims unless defined otherwise.
If a claim is denied for incorrect information, correct the claim and resubmit it, rather than calling Medicaid Information. Until the claim is billed correctly, it cannot be processed.
Claim Corrections through Re-Submission
Occasionally a claim is paid incorrectly (e.g., a line denied), if this occurs a replacement claim must be filed. Refer to the EOB for denial or payment information. The following data elements are required to identify the claim as a replacement or void of an original claim:
Claim Frequency Code
| Acceptable values: | 6 or 7 for replacement, 8 for void |
| Electronic: | X12 element 2300 CLM05-3 |
| Paper: | UB-04 - Form Locator 4, position 3 CMS 1500 (08/05) - Box 22 (Code) |
Dental - Process not available on paper.
Original Reference Number
Transaction Control Number (TCN) of original claim to be replaced or voided
| Electronic: | X12 element 2300 REF02 |
| Paper: | UB-04 - Form Locator 37 A-C (same line as Medicaid in 50A-C) CMS 1500 (08/05) - Box 22 (Original Ref. No.) |
Dental - Process not available on paper.
Replacement claims void the original claim and process the replacement claim. Consult with your programmer to verify the required data elements are available in your software. Claims submitted without a valid original reference number (TCN) will be rejected.
The NPI must be the same on both the replacement/void and the original claim. If providers are different, send a void for the original claim and resubmit an original claim for the correct provider.
Medicaid is a benefit only to eligible persons. Medicaid will not pay for services rendered to an individual who is not eligible for Medicaid benefits on the date the service is rendered. Medicaid will not make fee-for-service payments when a member is enrolled in an MCO unless the service is carved out. It is the provider’s responsibility to verify the individual’s eligibility for Medicaid for the date the service is rendered. It is also the provider’s responsibility to verify if the individual is enrolled in an MCO. Claims for ineligible individuals or claims that are the responsibility of an MCO will not be paid even when information was given in error by Medicaid staff. Staff make every effort to provide complete and accurate information on all inquiries.
With established national standard for electronic claims and other transactions, healthcare providers are able to use consistent procedures and codes when submitting transactions to a health plan anywhere in the United States.
Standards for nine electronic transactions and code sets are used in claims transactions. These include:
277 Claim Inquiry Response Transaction (Batch)
The 277 Transaction Set is used to transmit health care claim status inquiry responses to any health care provider, clearinghouse or other health care claims adjudication processors that has submitted a 276 to the Utah MMIS.
Enrollment (834 Transactions)
834 Enrollment Transaction
The 834 Transaction Set is used to transmit health care enrollment into an Accountable Care Organization (ACO). Medicaid uses this transaction to notify the ACOs that a Medicaid recipient has been enrolled in the ACO. The transaction provides the plan with the recipient’s demographics and some health data.
Remittance Advice (RA) (835 Transactions)
835 Remittance Advice
The 835 Transaction Set will only be used to send an Explanation of Benefits (EOB) RA. For Utah Medicaid, payment is separate from the EOB RA and will therefore not be affected by changes to how the provider receives payment. The 835 transaction will be available to the providers and contracted clearinghouses requesting electronic remittance advice (ERA). Providers may choose to receive ERA or paper RA, or both.
Premium Payment (820 Transactions)
820 Premium Payment Transaction
The 820 Transaction Set is used to transmit premium payment data to the ACO.
Prior Authorization (278 Transactions)
278 Referral Certification and Authorization. Health Care Service Review Transaction
The 278 Transaction Set is used to transmit requests for prior authorization of services.
Medicaid allows claims or prior authorization request submitters to continue billing their claims or PA requests electronically even if a paper attachment needs to be sent with the claim or PA request. If documentation is required to support the claim, the claim may deny; however, once documentation is received the claim will be reprocessed.
To ensure proper handling of attachments, ensure the attachment contains the following information:
All interactive electronic pharmacy claims should be submitted using the NCPDP version D.0 standard. All pharmacy claims submitted electronically in batch must be in NCPDP version 1.1 standard.
In accordance with Utah Administrative Code R414-522 and section 12006 of the 21st Century CURES Act, providers of Home Health and Personal Care Services (including similar services offered through the Home and Community-Based Waiver programs) must comply with Electronic Visit Verification (EVV) requirements.
Home Health and Personal Care Services providers may select the system of their choosing, provided it captures the following data elements and is compliant with the standards set in the Health Insurance Portability Accountability Act. EVV systems must the collect the minimum information:
Additional information, including technical specifications for file creation/submission can be found at https://medicaid.utah.gov/evv.
Correct coding guidelines encourage the reporting of all delivered services. Therefore, providers should report covered and non-covered services when billing acute inpatient hospital claims. However, there are instances where the Medicaid claims processing system will deny an entire claim for a single denied line. Generally, this occurs for services that require prior authorization, but the hospital did not obtain one.
When an entire claim denies for a non-covered line item(s), Medicaid requires that acute inpatient hospitals report covered services and omit non-covered services that would otherwise deny the claim. Additionally, providers must omit the reporting of any other ICD-10-PCS, CPT, HCPCS, or revenue codes related to the non-covered services.
For example, a member is admitted for labor and delivery and elects to have a sterilization procedure performed but does not have prior authorization for the sterilization. In this instance, the sterilization, and the associated services, are non-covered. The facility must omit the non-covered services from the claim.
Furthermore, if admission to an acute inpatient hospital is primarily for services not otherwise covered by Medicaid, all services performed for that episode of care are non-covered and will not be reimbursed. This policy stands regardless of whether or not Medicaid would have covered some of the services performed.
All Utah Medicaid claims require diagnosis codes and procedure codes. The appropriate diagnosis code must be entered on all claims. Procedure codes are dependent on the type of service and claim type. Medicaid recognizes guidelines in current editions of established coding manuals or other standard literature. However, those guidelines are adopted only as far as they are consistent with application to Utah Medicaid policy. The established coding guidance materials consist of the following:
International Classification of Diseases (ICD)
The International Classification of Diseases (ICD): Clinical Modification is a statistical classification system that arranges diseases and injuries into groups according to established criteria.
Revenue Codes (Uniform Billing Codes UB-04)
Uniform billing guidelines are a standard data set and format used by the health care community to transmit charge and claim information on hospital services to third party payers. The guidelines are developed on a national basis by the National Uniform Billing Committee. The Billing Manual is maintained and updates provided locally by the Utah Hospital and Health Systems Association. The approved codes in the Medicaid section of the UB-04 Manual are established consistent with Medicaid policy, reviewed and maintained by Medicaid staff periodically.
Industry updates to CPT, HCPCS, and ICD-10-CM codes are published toward the end of each year. Medicaid staff review each new edition of the coding manuals. The purpose of the review is to identify new services, eliminated services or procedures, and altered descriptions of service. Where additions, deletions, and/or changes have occurred, research is initiated with subsequent development of appropriate policy recommendations and rule-making to establish service coverage and/or limitations consistent with Medicaid policy. Notice of any change is given in the Medicaid Information Bulletin (MIB). All codes will be discontinued or added based on the date of implementation set by the standard setting organization.
Note: Coding information, clarification or review is not available through the Medicaid Information Hotline. In other words, Medicaid staff may not advise providers which codes to use.
Providers must observe CPT and Medicaid guidelines on classifying a patient either as new or as established. Under CPT guidelines, a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.
When a physician is on call for or covering for another physician, classify the patient’s encounter as it would have been by the physician who is not available. Medicaid considers any physician in the same clinic, group practice or other facility to be “of the same specialty” unless the member has specifically been referred to another physician of a different specialty for issues related to that specialty.
When an ICD-10-CM 'Z' code is used, an additional diagnosis code must also be added to the claim form. As always, the diagnosis and procedure codes must agree.
Examples:
Supplying the correct diagnosis and procedure codes for payment is the responsibility of the provider. The differential diagnosis must support the medical necessity of the procedure for reimbursement. Often, more than one diagnosis is required to explain and support a service. When the diagnosis does not support the procedure, a diagnosis to procedure discrepancy will be reported on the remittance advice. Providers should then resubmit a claim with additional or other appropriate diagnoses.
When the majority of procedures are related to a routine health visit and/or childhood immunizations, Z codes related to routine child health examinations, such as Z00.121, Z00.129, Z76.1, Z76.2, will be accepted alone for payment. However, when the child also has a medical condition that requires additional procedures (such as x-rays, laboratory examinations, etc.), include on the claim the ICD-10-CM code which describes the differential diagnoses for the medical condition. The ICD-10-CM codes assist in explaining the diagnostic test.
Claims submitted with a diagnosis which does not agree with the completed procedure will be denied. For example: A claim for CT of the abdomen which is submitted with diagnoses of headache and myalgia will not be paid. Also, with the exception of child health, maternal health, or refugee exams, claims submitted with only a Z code will not be paid; all claims require a code which describes the diagnoses for the medical condition.
Medicaid must have an accurate record of the diagnosis and procedures on submitted claims to evaluate programs and payment trends. Claim payment to providers is delayed when inaccurate diagnoses are submitted. Direct questions to Medicaid Operations (Refer to Chapter 1, General Information).
Many procedure codes contain time frames built into the definition. For billing services that fall between the time frames, Medicaid’s policy is to round to the nearest full unit or appropriate procedure code. No partial units may be reported.
The manual review of claims is reserved for specific types of claims. A provider may not request a manual review of a claim unless the denial meets the criteria found in this chapter. Upon receipt of a properly submitted request, medical staff trained in reviewing these claims manages each case.
To request manual review of a claim, complete the following steps.
Note: Documentation that is illegible, not applicable, or sent to an incorrect FAX number will not be returned or verified and the case will not be reviewed.
When the request is complete, the claim is reviewed and the provider is notified of the results.
All Modifiers are subject to manual review. For information on the manual review process see chapter 12-7 Manual Review.
Modifier 22: (Unusual procedural services) Modifier 22 is suspended for manual review. If approved, it will be paid at an additional 10% of the established fee schedule. Exception: multiple gestation births.
Modifier 24: Claims submitted with modifier 24 require the submission of documentation substantiating correct reporting of an Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period and qualifies for manual review. The provider may need to indicate that an E/M service was furnished during the postoperative period of an unrelated procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.
Additionally, modifier 24 is appropriately applied when it is used for anesthesia pain management service reporting. Documentation must include when the epidural or block injection is given relative to the general anesthesia.
Modifier 25: Claims submitted with modifier 25 require the submission of documentation substantiating correct reporting of a Significant, Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service and qualifies for manual review. Medicaid considers an E/M as a significantly separately identifiable service when the provider may need to indicate that on the day of service, the member's condition required an E/M above and beyond the other services provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the service was provided and therefore does not require a different diagnosis when reporting.
Coverage of diagnostic or therapeutic procedures includes taking vital signs, asking the member how they feel, and obtaining written consent. Therefore, it is not appropriate to report a different E/M code for these services per the National Correct Coding Initiative (NCCI) unless the criteria mentioned above are met. When these criteria are met, a provider may report the E/M by adding modifier 25 to the appropriate level of E/M service.
Modifier 26 and TC: Certain procedures and services have both a professional and a technical component. In procedures having a recognized technical/professional split the following coding guideline should be followed.
Append modifier 26 only for the professional (physician) component of a billed service.
Append modifier TC when only the technical component is being billed. In the event that the provider owns the radiology overhead and also reads the exam, then submit one line for the professional component with modifier 26 and a second line for the technical component unmodified to ensure reimbursement for the global service
Modifier 27: (Multiple Outpatient Hospital Evaluation and Management Encounters on the Same Day) Medicaid will not recognize Modifier 27. Modifier 27 is only appended to facility-based services performed in the hospital outpatient setting. Medicaid does not reimburse for services attached to Modifier 27.
Modifier 50: (Bilateral Procedures) Medicaid will not recognize modifier 50.
Modifier 51: (Multiple Procedures) When more than one procedure is performed during an operative session the surgeries are subject to the multiple surgery rules and are ranked in descending order by the Medicaid fee schedule allowed amount.
Modifier 52: (Reduced Service) Modifier 52 is paid at 50% of the established fee schedule.
Modifier 53: (Discontinued Procedure) Modifier 53 is paid at 50% of the established fee schedule.
Modifier 54: (Surgical Care Only) Modifier 54 is paid at 70% of the established fee schedule.
Modifier 55: (Post-Operative Management Only) Modifier 55 is paid at 20% of the established fee schedule.
Modifier 56: (Pre-Operative Management Only) Modifier 56 is paid at 10% of the established fee schedule.
Modifier 57: (Decision for surgery) Medicaid will not recognize modifier 57. Decision for surgery performed for the purposes of hospital accreditation requirements that indicate every patient must have an initial hospital history and physical, is not a covered service and is integral to the surgical global fee.
Modifier 59* and subsets: Are reviewed when the CPT code posts an incidental or mutually exclusive edit to the primary procedure. Submit documentation showing that the procedure is not a component of another procedure, but is a distinct, independent procedure. Mutually exclusive edits occur when two or more procedures that are usually not performed during the same member encounter on the same date of service. The less clinically intense procedure(s) is denied. Incidental edits occur when relatively minor procedures are performed at the same time as complex primary procedures, and are considered clinically integral to the performance of the primary procedure.
Modifier 59 and the subset modifiers are the modifiers of last resort and should not be used when a more descriptive modifier is available. The subset modifiers are more selective versions of the 59 modifiers so it would be incorrect to include both modifiers on the same line.
The provider may submit medical records supporting the distinct or independent identifiable nature of the service. Modifier 59 or a subset modifier, are considered for manual review only after editing program denial.
Modifier 62: (Two surgeons of a different specialty are required to perform a specific procedure) Modifier 62 is suspended for manual review and requires each co-surgeon to submit a separate operative report clearly describing the separate portions of the procedure that each surgeon completed. Modifier 62 is paid at 62.5% of the established fee schedule
Modifier 66: (Surgical Team) Modifier 66 is suspended for manual review and is priced by Medicaid physician consultants.
Modifier 73: (Discontinued outpatient hospital/ambulatory surgical center (ASC) procedure prior to the administration of anesthesia) Modifier 73 is to be utilized by facilities when an outpatient service is only partially completed or discontinued by the physician prior to completion of the service. This modifier may not be submitted by the operating surgeon. Only ASCs should submit this modifier. This modifier is to be paid at 50% of established fee schedule.
Modifier 74: (Discontinued outpatient hospital/ambulatory surgical center (ASC) procedure after the administration of anesthesia) Modifier 74 is to be utilized by facilities when an outpatient service is only partially completed or discontinued by the physician prior to completion of the service. This modifier may not be submitted by the operating surgeon. Only ASCs should submit this modifier. This modifier is to be paid at 50% of established fee schedule.
Modifier 76 or 77: When an edit posts that the claim is an exact duplicate of a paid claim, the claim is only manually reviewed when submitted with a 77 or 76 on the denied line. Submit documentation supporting the rationale for a repeated procedure or service by the same or another provider.
Modifier 80: (Assistant at Surgery) Modifier 80 for assistant surgeon is limited to 20% of the established fee schedule.
Modifier AS: (PA or NP assistant at surgery) Modifier AS for PA or NP assistants to surgery is limited to 20% of the established fee schedule.
Modifier 81: (Minimal assistant at surgery) Medicaid does not reimburse for services reported with Modifier 81.
Modifier 82: (Minimal surgical assistance is needed, but the qualified resident was not available) Medicaid does not reimburse for services reported with Modifier 82.
Modifier 91: Submit documentation supporting the claim that separate services were provided for a distinct medical purpose.
Each CPT, HCPCS, and PCS code has a designated rate and are weighted based on Relative Value Units (RVUs). These values are established based on the concept that the services reported are standalone procedures. In some instances, providers will perform multi-staged procedures that are separate but related to one another. In these instances, the expense of performing the associated procedures is reduced as they do not require a different surgical session, incisions, anesthesia, etc. This is known as Multiple Procedure Payment Reduction (MPPR). Multiple procedures performed during the same service session by the same provider are reported using modifier 51. Even if a modifier is not used, MPPR can be applied for services performed on the same date.
The MPPR applies to procedures when:
The MPPR will be applied using the pricing method outlined below:
Multiple Procedure Payment Reduction (MPPR) for Assistant Surgeon Services
Multiple procedures performed by an assistant surgeon or a nurse practitioner/physician assistant are subject to the MPPR concept defined above when performed by the same provider on the same service date. There are instances when a surgical procedure requires and allows for reporting an assistant surgeon. In these circumstances, the assistant surgeon reimbursement will be 20% of the allowable amount for each procedure.
Refer to Section I: General Information provider manual, Chapter 12-7.3, Modifier used in a Claim, for additional details related to reporting assistants to surgery.
Multiple Procedure Payment Reduction (MPPR) for Co-Surgeon/Team Surgeon Services
Multiple procedures performed by a co-surgeon are subject to the MPPR when performed by the same physician or other qualified health care professional on the same date of service. Co-surgeon and team surgeon services are considered separately and independently of any other co-surgeon or team surgeon services.
In cases where the service has been denied after manual review, the remittance advice indicates manually reviewed and denied. At this point the provider may consider submitting a request for a hearing. All hearing requests require a Request for Hearing/Agency Action form and supporting documentation in addition to that sent for the manual review.
A hearing request to appeal the denial of an unlisted CPT code also requires the following.
Current Procedural Terminology, American Medical Association, current edition
Health Care Procedure Coding System, HCPCS
Hearing decision numbers 13-078-02 and 13-239-03
State Plan Amendment
Attachment 3.1-A, Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy
Attachment 3.1-B, Amount, Duration, and Scope of Services Provided Medically Needy Group(s)
Social Security Act Titles XVIII, XIX, XXI, or XX
Social Security Act Sections 1902(a)(31)(A), 1903(v)(1), 1905(a)(19), 1905(o), 1915(g)
Title VI of the Civil Rights Act
Utah Administrative Code
R410-14
R414-1-2, 5, 14
R414-22
R590-164
Utah Code Annotated
§26-20-1, et seq, Utah False Claims Act
§26-18-2.1 (1953, as amended) Medical Assistance Act, Medical Assistance Programs, Division-Creation
§26-23-2-(1) UCA, (1953)
§63G-2
42 CFR
§431.52
§440 [October 1, 1996, edition]
§440.60, 170, 230, 255(c)
§455
§447.15, 45(d)(4)(iv)
§§1007.7 through 1007.13, State Medicaid Fraud Control Units
Following is a list of acronyms commonly used in the administration, policies, or procedures of Utah’s Medicaid Program.
|
ACO |
Accountable Care Organization |
|
ALOS |
Average length of stay |
|
ANSI |
American National Standards Institute |
|
ASC X12 |
Accredited Standards Committee (see definitions) |
|
CDEN |
Child Health Insurance Program Dental Claims |
|
CFR |
Code of Federal Regulations |
|
CHIP |
Children’s Health Insurance Program |
|
CLIA |
Clinical Laboratory Improvement Amendments |
|
CMS |
Centers for Medicare and Medicaid Services |
|
CPT |
Current Procedural Terminology |
|
DCFS |
Division of Child and Family Services |
|
DIH |
Division of Integrated Healthcare |
|
DHS |
Department of Human Services |
|
DHHS |
Department of Health and Human Services |
|
DRA |
Deficit Reduction Act |
|
DRG |
Diagnosis Related Group |
|
DUR |
Drug Utilization Review |
|
DWS |
Department of Workforce Services |
|
EDI |
Electronic Data Interchange |
|
EOB |
Explanation of Benefits |
|
EOMB |
Explanation of Medicare Benefits |
|
EPSDT |
Early Periodic Screening Diagnosis and Treatment |
|
EREP |
Electronic Resource and Eligibility Product |
|
FDA |
Food and Drug Administration |
|
FFP |
Federal Financial Participation |
|
FFS |
Fee for Service |
|
FPL |
Federal Poverty Level |
|
FR |
Federal Register |
|
GRAMA |
Government Records Access and Management Act |
|
HCBS |
Home and Community Based Services |
|
HCPCS |
Healthcare Common Procedure Coding System |
|
HHA |
Home Health Agency |
|
HHS |
Department of Health and Human Services (Federal) |
|
HIPAA |
Health Insurance Portability and Accountability Act |
|
HPR |
Health Program Representative |
|
ICD-9 |
International Classification of Diseases, Ninth Revision |
|
ICD-10 |
International Classification of Diseases, Tenth Revision |
|
ICF |
Intermediate Care Facility |
|
IPA |
Independent Practice Association |
|
LTAC |
Long Term Acute Care Hospital |
|
MCO |
Managed Care Organization |
|
MFCU |
Medicaid Fraud Control Unit |
|
MFU |
Medicaid Fraud Unit, now the MFCU |
|
MMCS |
Medicaid Managed Care System |
|
MMIS |
Medicaid Management Information System |
|
NCPDP |
National Council of Prescription Drug Programs |
|
NDC |
National Drug Code |
|
NPI |
National Provider Identifier |
|
NTM |
Non-Traditional Medicaid |
|
OBRM |
Omnibus Budget Reconciliation Act |
|
ORS |
Office of Recovery Services |
|
ORSIS |
Office of Recovery Services Information System |
|
PA |
Prior Authorization |
|
PERM |
Payment Error Rate Measurement |
|
PMHP |
Prepaid Mental Health Plan |
|
POS |
Point of Sale |
|
PPO |
Preferred Provider Organization |
|
PRO |
Peer Review Organization |
|
QMB |
Qualified Medicare Beneficiary |
|
RBRVS |
Resource-Based Relative Value Scale |
|
SNF |
Skilled Nursing Facility |
|
SSI |
Supplemental Security Income |
|
TANF |
Temporary Assistance to Needy Families |
|
TPL |
Third Party Liability |
|
UHA |
Utah Hospital Association |
|
UHCA |
Utah Health Care Association |
|
UHIN |
Utah Health Information Network |
|
UMA |
Utah Medical Association |
|
UPP |
Utah’s Premium Partnership |
|
WIC |
Special Supplemental Food Program for Women, Infants, and Children |
The following linked forms and attachments can also be found on the Provider Form Directory of the Utah Department of Health and Human Services Medicaid website.
Updated September 2022