Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUtah Medicaid Home Health Policy Update | OpenPaye…
    Ask Trek AI about this page
    CurrentUtah MedicaidPolicy 22-001125-0012

    Medically Necessary Services

    Customize your policy alerts

    Sign up for Utah Medicaid Policy 22-001125-0012 alerts

    Get alerted when Policy 22-001125-0012 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines medical necessity criteria for targeted case management for eligible Medicaid children and establishes reimbursement rules and geographic payment enhancements for home health services delivered statewide by Utah Medicaid providers.

    Policy Summary
    PayerUtah Medicaid
    PolicyMedically Necessary Services
    Policy CodePolicy 22-001125-0012
    Change TypeRevised
    Effective DateOct 1, 2022
    Next Review DateN/A
    Key ActionBill home health services using the applicable Utah Medicaid fee schedule and apply rural, county-specific, or remote-zone payment rules when the service location and travel conditions qualify.
    SourceLink
    POLICY UPDATE CHANGES

    Targeted case management eligibility is described for Medicaid-eligible children from birth until the child turns eight years old.

    Home health reimbursement includes enhanced payment factors for services provided in San Juan County and Grand County and for specified remote service zones.

    Birth through age 8Targeted case management age eligibility
    StatewideService availability
    25 milesRural enhancement travel threshold

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1.75x
    Rural travel multiplier
    4.08x / 2.95xCounty multipliers
    7.12x / 15.02xRemote-zone multipliers

    Medical Necessity and Reimbursement Criteria

    Targeted Case Management Medical Necessity

    Targeted case management is covered for Medicaid-eligible children from birth until the child turns eight years old when ALL of the following medical-necessity conditions are met.

    ALL of the following

    • The individual requires treatment and/or services from a variety of agencies and providers to meet documented medical, social, education, and other needs.
    • A needs assessment completed by a qualified targeted case manager documents the individual's needs.
    • There is a reasonable indication that the individual will access needed services only if assisted by a qualified targeted case manager who, in accordance with an individualized case management service plan, locates, coordinates, and regularly monitors the services.

    Home Health Reimbursement Criteria

    Home health reimbursement is subject to the following fee-schedule, billing, and applicable geographic-enhancement criteria.

    Base reimbursement criteria

    • Unless otherwise noted in the plan, state-developed fee schedule rates apply to both governmental and private providers.
    • Payment is based on the established fee schedule unless a lesser amount is billed.
    • The amount billed cannot exceed the provider's usual and customary charges to private-pay patients.
    • For claims billed through the medical benefit, rates are effective for services provided on or after the date listed on the Attachment 4.19-B Introduction Page.
    • For claims billed through the pharmacy point of sale, reimbursement follows the reimbursement set forth in Attachment 4.19-B for prescribed drugs.

      Medical-benefit rates are published at http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.

    Applicable geographic enhancement

    Codes, Modifiers, and Geographic Payment Factors

    Excluded personal care codeHCPCSNot Covered
    T1019Personal care claim code excluded from the San Juan County and Grand County home health enhancement factors
    Remote-zone home health modifiersModifierCovered
    UAModifier for Home Health Agency services for Zone 1 residents or eligibles
    UBModifier for Home Health Agency services for Zone 2 residents or eligibles
    Rural enhancement travel threshold
    Minimum one-way distanceMore than 25 miles
    Measurement pointFrom the provider’s base of operations
    Applicable servicesHome health services provided in qualifying rural counties
    Higher rural multiplier travel threshold
    Travel threshold50 miles or more one way
    Payment factor1.75 times the Home Health fee schedule
    Payment basis

    Documentation, Care Planning, and Billing Actions

    Documentation Required

    Document targeted case management medical necessity

    Complete and retain a needs assessment by a qualified targeted case manager. The assessment must document that the child requires treatment or services from a variety of agencies and providers and is reasonably likely to access needed services only with assistance from a qualified targeted case manager.

    • Document the child’s medical, social, educational, and other needs.
    • Document the need for assistance locating, coordinating, and regularly monitoring services.
    Documentation Required

    Maintain the individualized case management plan

    Develop and maintain a written, individualized, and coordinated case management service plan. Coordinate service delivery, monitor the quality and appropriateness of services, periodically reassess the child’s status, and modify the plan as needed.

    • Include input, as appropriate, from the client, family, and other agencies knowledgeable about the child’s needs.

    Key Policy Definitions

    Targeted case management
    Service definitionAssists eligible clients in gaining access to needed medical, social, educational, and other services
    Coordination purposeEnsures services are coordinated among all involved agencies and providers
    Covered activitiesIncludes assessing needs, linking clients to resources, coordinating delivery, and monitoring service quality and appropriateness
    Target group
    EligibilityMedicaid-eligible child
    Age rangeFrom birth until the child turns eight years old
    Medical necessity
    Policy Summary
    PayerUtah Medicaid
    PolicyMedically Necessary Services
    Policy CodePolicy 22-001125-0012
    Change TypeRevised
    Effective DateOct 1, 2022
    Next Review DateN/A
    Key ActionBill home health services using the applicable Utah Medicaid fee schedule and apply rural, county-specific, or remote-zone payment rules when the service location and travel conditions qualify.
    SourceLink
    On This Page
    Medical Necessity and Reimbursement CriteriaCodes, Modifiers, and Geographic Payment FactorsDocumentation, Care Planning, and Billing ActionsKey Policy Definitions

  1. Rural-area exception

    • The service is provided in a rural county, defined as a county other than Weber, Davis, Salt Lake, or Utah County.
    • One-way travel from the provider's base of operations exceeds 25 miles.> 25 miles
    • For travel of 50 miles or more, the applicable Home Health fee schedule is multiplied by 1.75 to calculate payment for applicable service codes.>= 50 miles

  2. San Juan County exception

    • The service is provided in San Juan County.
    • The Home Health fee schedule is multiplied by 4.08 to calculate payment for applicable service codes.
    • The enhancement applies irrespective of travel distance and is in lieu of the rural-area exception.
    • Personal care claims billed using code T1019 are excluded.

  3. Grand County exception

    • The service is provided in Grand County.
    • The Home Health fee schedule is multiplied by 2.95 to calculate payment for applicable service codes.
    • The enhancement applies irrespective of travel distance and is in lieu of the rural-area exception.
    • Personal care claims billed using code T1019 are excluded.

  4. Zone 1 remote-area enhancement

    • The resident or eligible is located in Aneth or Hatch Trading Posts, or in Mexican Hat or Montezuma Creek.
    • Home Health Agency services are billed with Modifier UA.
    • The existing Home Health Agency fee schedule is multiplied by 7.12.

  5. Zone 2 remote-area enhancement

    • The resident or eligible is located in Monument Valley.
    • Home Health Agency services are billed with Modifier UB.
    • The existing Home Health Agency fee schedule is multiplied by 15.02.
    6. Used to calculate the payment rate for applicable service codes
    San Juan County home health multiplier
    CountySan Juan County
    Payment factor4.08 times the existing Home Health fee schedule
    Travel requirementApplied irrespective of the distance traveled
    Grand County home health multiplier
    CountyGrand County
    Payment factor2.95 times the existing Home Health fee schedule
    Travel requirementApplied irrespective of the distance traveled
    Zone 1 remote-area multiplier
    Billing modifierUA
    Payment factor7.12 times the existing Home Health Agency fee schedule
    Applicable areaZone 1 remote areas
    Zone 2 remote-area multiplier
    Billing modifierUB
    Payment factor15.02 times the existing Home Health Agency fee schedule
    Applicable areaZone 2 remote areas
  6. Link the child with community resources and needed services.
  7. Coordinate services, including CHEC screenings and follow-up.
  8. Monitor services and reassess the child’s status periodically.
    9. Billing Rule

    Apply home health reimbursement rules

    Bill home health services using the established Utah Medicaid fee schedule unless a lesser amount is billed, and do not bill more than usual and customary charges to private-pay patients. Apply the applicable rural, county-specific, or remote-zone payment rule based on the service location and qualifying travel conditions.

    • In qualifying rural counties, one-way travel must exceed 25 miles from the provider’s base of operations for an enhancement; travel of 50 miles or more uses a 1.75 multiplier.
    • For San Juan County and Grand County, use the 4.08 and 2.95 multipliers, respectively, in lieu of the rural-area exceptions.
    • For eligible remote zones, bill Modifier UA for Zone 1 and Modifier UB for Zone 2, with the applicable 7.12 or 15.02 multiplier.
    Denial Risk

    Exclude T1019 from county enhancements

    Exclude personal care claims billed with code T1019 from the San Juan County and Grand County home health enhancement factors. These county enhancements apply to applicable home health services, but not to personal care claims using T1019.

    • San Juan County factor: 4.08 times the existing home health fee schedule for applicable services.
    • Grand County factor: 2.95 times the existing home health fee schedule for applicable services.
    Targeted case management must be determined to be medically necessary
    Rural county
    Geographic definitionA county other than Weber, Davis, Salt Lake, or Utah County
    Excluded countyWeber County
    Excluded countiesDavis, Salt Lake, and Utah counties
    Zone 1
    Included locationsAneth Trading Post and Hatch Trading Post
    Additional residents or eligiblesMexican Hat and Montezuma Creek
    HHA billing modifierUA
    Zone 2
    Included locationMonument Valley residents or eligibles
    HHA billing modifierUB
    Payment factor15.02 times the existing Home Health Agency fee schedule