With the implementation of the Provider Reimbursement Information System for Medicaid (PRISM), the legacy Medicaid Management Information System (MMIS) froze operation on March 10, 2023 at 5:00 PM. A replacement tool will be posted after PRISM go-live before the end of April. This site will remain active, but will only be functional for payment dates on or before March 10, 2023.

Utah Medicaid is in the process of replacing MMIS and MMCS with a new system called PRISM, which will go-live on April 3, 2023.  In preparation, the Medicaid systems will “freeze” operations from March 13 through April 2, 2023. The system freeze will impact provider enrollment, claims processing and payments, medical prior authorizations, and pharmacy prior authorizations for pharmacy-related HCPCS codes.

For more information and trainings, please visit medicaid.utah.gov/prism.

IMPORTANT NOTICE

Utah Medicaid is committed to ensuring our members continue to receive products and services with no interruptions or delays due to the novel coronavirus (COVID-19) outbreak. In response, Utah Medicaid is temporarily modifying certain policy conditions to allow for increased quantity limits for those medical supplies that are refilled on a monthly basis. This action is not intended to allow for unnecessary stockpiling of medical supplies but rather to help those vulnerable populations that have been directed to limit contact with other persons as part of the CDC guidance for “social distancing” or when required to be quarantined due to an active infection. Furthermore, PA requirements have been removed from CPAP, BiPAP, and sip and puff equipment in order to increase the ease of access to these items when determined to be medically necessary by a physician as outlined in the Utah Administrative Code R414-10-2(3).

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.

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.