Select Health Community Care — Operational policy for managed Medicaid plan services
Operational policy governing Select Health Community Care (a managed Medicaid plan) services, provider network, member billing, preauthorization, care management, and integrated Medicaid plan rules for Select Health members in Utah.
No material clinical or coverage changes in this revision.
Coverage rules and member billing
Coverage overview
General coverage principles and exclusions
Integrated plan mental health rules
Integrated plan mental health coverage
Member billing policy
Member billing restrictions
ALL of the following
- The member is clearly advised prior to receiving the noncovered service that the plan will not pay and the member will be responsible for full cost.
- The member agrees in writing to be personally responsible for payment and the agreement details the service and amount to be paid.
- The provider has an established policy for billing patients for services not covered by a third party.
Utilization management
Inpatient status reviews
Billing codes and turnaround metrics
| Refer to Utah Medicaid Coverage and Reimbursement Tool for codes for comprehensive annual exams. |
Preauthorization, documentation, and denial risks
Prior Authorization Required
Preauthorization is required for many services. Preauthorization criteria were developed with SelectHealth physician leadership. Access online preauthorization forms and the Preauth & Care Plan Tool (an online streamlined process that shortens turnaround time). Submit completed preauthorization forms with relevant clinical notes and medical necessity information for Medicaid members via the Care Affiliate 24/7 Help Desk at 800-442-4566 or by email to medicaidUMintake@imail.org.
- Preauthorization forms available online
- Preauth & Care Plan Tool for shorter turnaround times
- Submit clinical notes and medical necessity information
Urgent Request Pathway — Phone Only
Only urgent preauthorization requests are accepted by phone at 800-442-5305. Standard request turnaround time is 14 days; urgent request turnaround time is 72 hours.
- Urgent requests: phone only at 800-442-5305
- Standard turnaround: 14 days
- Urgent turnaround: 72 hours
Denial Risk and Retrospective Review
If a contracted provider submits a claim for a service that requires preauthorization without having obtained it, payment will be denied. If the provider resubmits the claim with records, the claim will undergo retrospective medical review and applicable preauthorization criteria will be applied. If the service is determined to be medically necessary and covered, the claim will be paid but subject to a 25% reduction of the allowed amount. Members may not be balance billed for this reduced amount. If the service is found not medically necessary or not covered, the claim will be denied. If the provider is unwilling or unable to provide medical records, the claim will be denied for lack of information.
- Failure to obtain required preauthorization → initial denial
- Resubmission with records → retrospective medical review
- If medically necessary and covered → payment with 25% reduction of allowed amount (no member balance billing)
- If not medically necessary or not covered → claim denied
- If records not provided → claim denied for lack of information
Pharmacy Preauthorization Note
Some pharmacy services have special requirements, including preauthorization. Refer to Select Health Drugs with Special Requirements for the list of medications and pharmacy-related prior authorization policies.
- See Select Health Drugs with Special Requirements for pharmacy preauthorization rules
- Residential and inpatient mental health treatment require preauthorization; for details call Member Services at 800-538-5038
Key terms
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.