Please note: The Coverage and Reimbursement Lookup Tool by Utah Medicaid has undergone recent updates to include new information from the PRISM system. We've recognized some inconsistencies where the tool does not accurately mirror current policy. We are actively working to resolve these issues and ensure the tool accurately represents Medicaid policy. As always, policy and coverage details are provided in Utah Medicaid provider manuals. You can find the manuals here.
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.
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.
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 details from Legacy (Pre-PRISM) Coverage Lookup Tool, please use this Legacy Coverage Lookup Tool.