With the implementation of the Provider Reimbursement Information System for Medicaid (PRISM), the legacy Coverage and Reimbursement Code Lookup will no longer be an up-to-date resource for verifying code-specific policies. This tool will remain active, but will only be functional for payment dates on or before March 10, 2023.

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IMPORTANT NOTICE

The information provided by this lookup tool does not guarantee reimbursement, but is intended to provide coverage and reimbursement information for selected procedure codes as of the "Updated On" date specified in the search results. For additional information regarding specific billing requirements and coverage or rates not managed in this Lookup tool, please consult the Medicaid Provider Manuals or contact us.

This fee schedule does not apply to hospital outpatient services paid under the Outpatient Prospective Payment System (OPPS), Indian Health Services (IHS), School Based Skills Development (SBSD), nor does it apply to Utah's 1915(c) HCBS waivers. Medicaid covered claims adjudicated through OPPS will be paid according to the applicable Medicare fee schedule, IHS providers are generally paid using the All-Inclusive Rate (please refer to the Indian Health provider manual for more specifics) and 1915(c) HCBS waiver providers should refer to the appropriate waiver-specific fee schedule.

For a list of provider types for which coverage and/or rates do not apply (as shown by this lookup tool), please click here.

Generally, the fees represented here are only for fee-for-service claims paid directly by Utah Medicaid using Utah Medicaid's fee schedule. This fee schedule does not account for any enhancement in fee schedule amounts (i.e., rural physician enhancements, rural dental enhancements, etc.).

The prior authorization requirements listed in this tool are applicable for services requested and billed directly to Utah Medicaid.

All Individuals eligible under Targeted Adult Medicaid are eligible for Traditional Medicaid. Individuals eligible under Adult Expansion Medicaid are eligible for the following: Adults with a dependent child living in the home will receive Non-Traditional Medicaid; Adults without a dependent child living in the home will receive Traditional Medicaid.

All individuals eligible for Primary Care Network (PCN) are transitioned to Adult Expansion Medicaid effective 4/1/2019. Information regarding the PCN program will be available for reference until 4/1/2020.

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Download by Plan Type:

These files do not contain provider specific information that is available in the lookup tool found at CoverageLookup. To download provider specific files please use the links provided in the "Provider Specific Downloads" section below.

Select the Plan Type and Date of Service, then click the Download button below to generate a comma separated (.csv) file.

Select Plan Type: Traditional Non-Traditional Primary Care Network

Date of Service:   (MM/DD/YYYY)

* CSV files can be opened using Microsoft Excel or other spreadsheet programs.

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Provider Type Specific Downloads:

This download contains provider specific information. If you are looking for general fee schedule information please use the download feature above.

Select the Plan Type, Provider Type and Date of Service, then click the Download button below to generate a comma separated (.csv) file.

Select Plan Type: Traditional Non-Traditional Primary Care Network

Select Provider Type: - 01 - General Hospital02 - Mental Hospital03 - Chronic Disease Hospital10 - Nursing Home12 - State Training School20 - Physician24 - Osteopath25 - Physician Assistant26 - QMB-Only Prov27 - Social Services Worker28 - Psychologist29 - Cert Social Worker30 - Podiatrist31 - Optometrist32 - Speech Pathologist33 - Occupational Therapist34 - Audiologist35 - Physical Therapist36 - Free Standing Birth Ctr37 - Cert Nurse Midwife38 - Nurse Anesthetist39 - Registered Nurse40 - Dentist41 - Clinical Social Worker42 - Health Educator43 - Dietitian44 - Marriage/Fam/Therapist45 - Group Practice46 - Agency/Hmkr/Rsp47 - Nurse Practitioner48 - LPN49 - PT/OT Rehab Cntr50 - Alcohol Drug Center51 - PH Dept Clinic52 - Fed Qu Health Center53 - Dialysis Center54 - Personal Care Agency55 - Free Standing Ambu/Surg56 - Mental Health Center57 - Rural Health Clinic58 - Mcare/Mcaid Certified Home Health Agency59 - Hospice60 - Pharmacy61 - Pharmacist62 - Medical Supplier63 - Optical Supplier64 - Adult Day Care65 - Emergency Rspn System66 - Transportation67 - Home Delivered Meals68 - Personal Care Waiver Services Agent69 - Chiropractor70 - Ind Lab and/or X-Ray71 - Mobile Ultrasound74 - Diabetes Self-Mngmnt Ed75 - Res Treatment Facility76 - Day Treatment Facility77 - Day/Res Treatment Facility78 - Support Coordination Agency81 - Ambulance82 - Servcar/Ambucar83 - Utah Tribal NEMT84 - Helicopter85 - Taxi88 - School District89 - Early Intervntn90 - Health Maintenance Org91 - Indian Health Services95 - Oral Surgeons

Date of Service:   (MM/DD/YYYY)

* CSV files can be opened using Microsoft Excel or other spreadsheet programs.

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Provider Pricing File ONLY:

Select the Date of Service, then click the Download button below to generate a comma separated (csv) file containing a list of the Procedure Codes, Provider Types, and Charge Factors for ALL provider specific pricing.

Date of Service:   (MM/DD/YYYY)

* CSV files can be opened using Microsoft Excel or other spreadsheet programs.

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HCPCS/NDC Crosswalk:

Select the Date of Service, then click the Download button below to generate a comma separated (csv) file containing a list of the HCPCS Codes and NDCs.

Date of Service:   (MM/DD/YYYY)

* CSV files can be opened using Microsoft Excel or other spreadsheet programs.

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Revenue Code Download by Plan Type:

NOTES:
• 1. NDC required for Provider Administered Drugs
• 2. Revenue Code 760 used for Long Term Acute Care (LTAC) only
• 3. This list does not guarantee coverage

Select the Plan Type and Date of Service, then click the Download button below to generate a comma separated (.csv) file.

Select Plan Type: Traditional Non-Traditional Primary Care Network

Date of Service:   (MM/DD/YYYY)

* CSV files can be opened using Microsoft Excel or other spreadsheet programs.