IMPORTANT NOTICE

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.

For instructions on how to navigate the fee schedule - Please see this document Accessing Coverage and Reimbursement Information

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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

Date of Service:   (MM/DD/YYYY)

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

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Provider Allowable Code (PAC) 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 Allowable Code (PAC) and Date of Service, then click the Download button below to generate a comma separated (.csv) file.

Select Plan Type: Traditional Non-Traditional

Select Provider Allowable Code: - Acquired Brain Injury Waiver - 142Agency - 116Aging Waiver - 144Ambulance - 134Ambulatory Surgical Center - 101Applied Behavioral Analyst - 166Audiologist - 034Behavioral Health Coach - 176Behavioral Health Technician - 177Certified Nurse Midwife - 017Certified Registered Nurse Anesthetist (CRNA) - 013Certified Social Worker (CSW) - 108Chiropractic - 018Chronic Disease Hospital - 102Clinical Mental Health Counselor - 162Clinical Social Worker (LCSW) - 111Community Mental Health Center - 122Community Supports Waiver - 145Community Transitions Waiver - 167Dental - 028Dental Hygienist - 169Diabetes Education-OPH - 057Dialysis Center - 119Dietician - 113Early Intervention - 138Employment Related Personal Assistant Services - 150Federally Qualified Health Center (FQHC) - 066Free Standing Birthing Center - 110General Hospital - 100Genetic Counselor - 174Group Practice - 115Health Care Facility - 158Health Educator (Childbirth Education) (CBED) - 112Health Maintenance Organization - 139Home Health Agency - 035Hospice - 005Housing Related Services and Supports - 171ICF/ID - 047Inpatient Rehabilitation Facility - 165Laboratory - 054Limited Supports Waiver - 168Local Health Department - 064Marriage/Family Therapist (MFT) - 114Master Addiction Counselor - 175Maxillofacial Surgery - 007Medical Supplier-DME - 021Medically Complex Children's Waiver - 146Mobile Ultrasound - 129NEMT (Indian Health) - 136New Choices Waiver - 147Nurse Practitioners - 062Nursing Facility - 037Occupational Therapist -Private Practice - 032Optometry - 023PT/OT Rehabilitation Center - 117Peer Support Specialist - 159Personal Care Agency - 120Personal Waiver Services Agent - 128Pharmacist - 170Pharmacy - 123Physical Disabilities Waiver - 148Physical Therapist -Private Practice - 026Physician Assistant - 140Physicians - 033Podiatry - 027Private Duty Nursing - LPN - 009Private Duty Nursing - RN - 010Psychologist (PHD) - 107Psychosocial Rehabilitative Services Worker - 160Recreational Therapy - 173Rural Health Clinic (RHC) - 067SUD & Mental Health Facilities - 118School Based Services - 030Servcar/Ambucar - 135Social Services Worker (SSW) - 106Speech Pathologist - 109State Psychiatric Hospital - 048Substance Use Disorder Counselor - 163Targeted Case Manager - 161Taxi - 137Technology Dependent Waiver - 149Tribal Health Center (THC) - 068Vision Contractor - 038

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 Allowable Codes (PAC), 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:

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

Date of Service:   (MM/DD/YYYY)

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