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), Federally Qualified Health Center (FQHC), Rural Health Clinics (RHC), 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.
Medicaid coverage of laboratory services is dependent upon facilities meeting the Clinical Laboratory Improvement Amendments (CLIA) provider certification requirements.
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.
Be advised, prior authorization does not guarantee payment. All submitted claims must be reported using correct coding (NCCI) guidelines and adhere to all Medicaid requirements and laws in order to receive reimbursement for services approved.
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.
As of Jan 1, 2024, all Medicaid members will be moved to the Traditional plan. The Non-traditional plan will no longer be effective past this date.
If you would like to view the entire fee schedule, rather than searching for a particular code, please use our Fee Schedule Download Tool.
If you would like to view the entire diagnosis schedule, please use our Diagnosis Schedule Download Tool.
If you would like to view the details from Legacy (Pre-PRISM) Coverage Lookup Tool, please use this Legacy Coverage Lookup Tool.