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    OpenPayerPolicy UpdatesReimbursement/Payment PolicyUtah Medicaid Nursing Facility Update | OpenPayer
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    ModifiedUtah MedicaidPolicy UT-24-0003

    Nursing Facility UPL and Routine Services Updates

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    This policy governs Medicaid reimbursement for nursing facilities, including routine and non-routine services, per diem rate components, resident-charge limitations, and upper payment limit methodology. It affects Utah Medicaid nursing facilities and providers furnishing services to residents during a Medicaid-covered facility stay.

    Policy Summary
    PayerUtah Medicaid
    PolicyNursing Facility UPL and Routine Services Updates
    Policy CodePolicy UT-24-0003
    Change TypeModified
    Effective DateJul 1, 2026
    Next Review DateN/A
    Key ActionDo not bill routine services separately during a Medicaid member's nursing facility stay because the daily nursing facility rate covers those services.
    SourceLink
    POLICY UPDATE CHANGES

    The upper payment limit supplemental payment methodology removes references to Medicare's resource utilization group model and uses the patient-driven payment model for comparison with Medicare payment for routine services.

    Routine and non-routine nursing facility services are updated to align, with exceptions, to services covered under Medicare's PDPM rates.

    Routine services furnished by providers during a member's nursing facility stay are included in the facility's daily rate and are not separately reimbursable.

    PDPMMedicare payment model used for the UPL comparison methodology
    RUG removedPrior resource utilization group references removed from the UPL supplemental payment section

    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.

    3Components of the nursing facility baseline per diem: Case Mix, flat rate, and property
    Routine servicesServices included in the nursing facility daily rate and generally not separately reimbursable

    Routine and Exception Coverage Rules

    Routine Services Covered by the Daily Rate

    Routine services are included in the nursing facility's daily rate and are not separately reimbursable during the Medicaid member's stay in the facility.

    Services identified as "routine" in Attachment 4.19-D, Section 920, when rendered by providers in this Attachment, are covered by the daily rate paid to the nursing facility and are not separately reimbursable during the member's facility stay.

    Because of differences in claim-submission timing, a provider may initially be reimbursed for a routine service that is later denied, with the paid amounts recovered.

    Exception Criteria

    The Agency may exceed limitations on existing covered services only to the extent allowed by law and when its medical staff determines that all of the following criteria are met:

    ALL of the following

    • The proposed services are medically appropriate.
    • The proposed services are more cost effective than alternative services.

    Billing Requirements and Payment Risks

    Billing Rule

    Routine Services Included in Daily Rate

    Services identified as routine in Attachment 4.19-D, Section 920, are not separately reimbursable while a Medicaid member is staying in a nursing facility. The nursing facility’s daily rate covers these routine services.

    • Do not bill routine services separately during the member’s Medicaid-covered nursing facility stay.
    Denial Risk

    Post-Payment Denial and Recovery Risk

    Because claims may be submitted at different times, a provider may initially receive payment for a routine service. That payment may later be denied, and the Medicaid program may recover the funds.

    • Treat any initial payment for a routine service as subject to post-payment review.

    Reimbursement Terms

    Baseline per diem rate
    Case Mix componentIncluded in the baseline per diem rate; see Section 921.
    Flat rate componentIncluded in the baseline per diem rate; see Section 922.
    Property componentIncluded in the baseline per diem rate; see Section 600.
    Patient-Driven Payment Model (PDPM)
    MethodologyPatient-Driven Payment Model (PDPM).
    PurposeUsed to calculate the nursing facility upper payment limit by comparing Medicaid and Medicare payment for the same set of routine services.
    Continuation
    Policy Summary
    PayerUtah Medicaid
    PolicyNursing Facility UPL and Routine Services Updates
    Policy CodePolicy UT-24-0003
    Change TypeModified
    Effective DateJul 1, 2026
    Next Review DateN/A
    Key ActionDo not bill routine services separately during a Medicaid member's nursing facility stay because the daily nursing facility rate covers those services.
    SourceLink
    On This Page
    Routine and Exception Coverage RulesBilling Requirements and Payment RisksReimbursement Terms
  1. Be prepared for denial and recovery when the service is determined to be included in the nursing facility’s daily rate.
    2. Prior Authorization

    Exception Requires Agency Medical Staff Authorization

    The Agency may exceed limitations on existing covered services, to the extent allowed by law, when its medical staff authorizes the exception based on the proposed service being medically appropriate and more cost-effective than available alternatives.

    • Obtain Agency medical staff authorization before providing or billing services outside existing covered-service limitations.
    • Document medical necessity and that the proposed service is more cost-effective than alternative services.
    The state intends to use PDPM until Medicare changes its reimbursement methodology again.
    Prior methodology referenceReferences to Medicare's resource utilization group (RUG) model are removed from the upper payment limit supplemental payment section.
    Routine services
    DefinitionServices included in the nursing facility daily rate.
    Separate reimbursementRoutine services are not reimbursable separately during the Medicaid member's facility stay.
    Facility responsibilityThe nursing facility daily rate covers routine services rendered by providers during the member's stay.
    Payment riskA routine-service claim may initially be reimbursed because of claims-submission timing and later be denied, with payment recovered.