RetiredUtah MedicaidPolicy N/A

Targeted Case Management for HMO Enrollees

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This state plan section governed targeted case management for Medicaid-eligible HMO enrollees and potential enrollees who needed assistance identifying, accessing, and coordinating medical or other services. The targeted case management service and payment provisions were deleted because the applicable HMO enrollee population no longer exists.

Policy Summary

PayerUtah Medicaid

PolicyTargeted Case Management for HMO Enrollees

Policy CodePolicy N/A

Change TypeRemoval of coverage and payment provisions

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionDo not bill or seek payment under the deleted targeted case management provisions for HMO enrollees or potential enrollees.

SourceLink

POLICY UPDATE CHANGES

Targeted case management service and payment provisions for HMO enrollees and potential enrollees were removed because the population no longer exists.

0Continued coverage under deleted HMO targeted case management provisions

120%Enhanced dental reimbursement ceiling

112%Rural certified nurse-midwife rate adjustment

12%

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RetiredUtah MedicaidPolicy N/A

Targeted Case Management for HMO Enrollees

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Policy Summary

PayerUtah Medicaid

PolicyTargeted Case Management for HMO Enrollees

Policy CodePolicy N/A

Change TypeRemoval of coverage and payment provisions

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionDo not bill or seek payment under the deleted targeted case management provisions for HMO enrollees or potential enrollees.

SourceLink

POLICY UPDATE CHANGES

Targeted case management service and payment provisions for HMO enrollees and potential enrollees were removed because the population no longer exists.

0Continued coverage under deleted HMO targeted case management provisions

120%Enhanced dental reimbursement ceiling

112%Rural certified nurse-midwife rate adjustment

12%

Rural nurse practitioner rate differential

100 clientsAnnual client commitment for qualifying urban dental providers

Coverage and Reimbursement Criteria

Former targeted case management eligibility

The former targeted case management provisions were deleted effective July 1, 2026 and are no longer available under this section.

ALL of the following

Individual was a Medicaid-eligible HMO enrollee or potential enrollee.
A qualified case manager determined that the individual required assistance to identify, obtain access to, and coordinate medical and other services consistent with the individual's identified needs.
There was a reasonable indication that the individual would obtain the required assistance only through a qualified targeted case manager.

Dental reimbursement criteria

Dental services are reimbursed under the established fee schedule, with enhanced payment provisions for qualifying providers in urban and rural counties.

Applicable payment pathway

ALL of the following
- A covered dental service is provided.
- A lesser amount is billed.
ALL of the following
- The provider is a dental provider in an urban county.
- The provider is not a state-funded clinic.
- The provider agrees to see at least 100 clients during the next year.>= 100 clients

Certified nurse-midwife reimbursement criteria

Certified registered nurse-midwife services are reimbursed using selected HCPCS codes, with a rural rate adjustment where applicable.

Applicable payment pathway

ALL of the following
- The certified registered nurse-midwife service uses a selected HCPCS code.
ALL of the following
- The certified registered nurse-midwife service uses a selected HCPCS code.
- The service is provided in a rural area.

Nurse practitioner and audiology reimbursement criteria

Nurse practitioner and covered audiology services are reimbursed under approved procedure codes and applicable fee schedules, with a rural differential for nurse practitioner services.

Applicable payment pathway

ALL of the following
- A licensed nurse practitioner performs an approved procedure.
ALL of the following
- A licensed nurse practitioner performs an approved procedure.
- The service is rendered in rural Utah.
ALL of the following

Codes, Rates, and Payment Parameters

Selected certified registered nurse-midwife procedure codesHCPCSCovered

No codes listed

Approved nurse practitioner procedure codesmixedCovered

No codes listed

Urban Dental Enhanced-Payment Commitment

Client commitmentUrban dental providers must agree to see 100 or more clients during the next year.

Provider eligibilityThe enhanced-payment agreement is available to dental providers excluding state-funded clinics.

Geographic scopeThe urban counties are Cache, Weber, Davis, Salt Lake, and Utah counties.

Enhanced Dental Reimbursement Ceiling

Enhanced reimbursement ceilingPayment may be up to 120% of the established fee schedule.

Payment limitationPayment is limited to the lesser of billed charges or 120% of the established fee schedule.

Provider Billing and Operational Actions

Denial Risk

Targeted Case Management Provisions Deleted

Targeted case management service and payment provisions for HMO (“Plan”) enrollees and potential enrollees were deleted effective July 1, 2026. Do not bill or seek payment under the deleted HMO targeted case management provisions.

The deleted provisions covered targeted case management for eligible HMO enrollees and potential enrollees.
The deleted service area included Davis, Salt Lake, Utah, and Weber counties.
The deleted qualified providers were Health Program Representatives employed by the Utah Department of Health, Division of Health Care Financing, Bureau of Managed Health Care.

Billing Rule

Non-Duplication of Payment

Key Terms and Geographic Definitions

Targeted Case Management Services

PurposeAssistance to eligible individuals to identify and appropriately utilize available medical and other services.

Coordination activitiesServices include assessment, referral, coordination, periodic follow-up, and assistance as service needs change.

Independent access instructionThe client or the client's legal representative may be instructed in independently identifying, obtaining, and coordinating needed services.

Qualified Providers

Provider classificationQualified providers are Health Program Representatives.

Employing entityThe representatives are employed by the State of Utah, Division of Health Care Financing.

Policy Summary

PayerUtah Medicaid

PolicyTargeted Case Management for HMO Enrollees

Policy CodePolicy N/A

Change TypeRemoval of coverage and payment provisions

Effective DateJul 1, 2026

Next Review DateN/A

Key ActionDo not bill or seek payment under the deleted targeted case management provisions for HMO enrollees or potential enrollees.

SourceLink

On This Page

ALL of the following

The provider is a dental provider in a rural county.

A covered audiology service is provided.

Applicable providersThe enhanced ceiling applies to qualifying urban dental providers and dental providers in rural counties, including state-funded clinics in rural counties.

Rural Certified Nurse-Midwife Rate Adjustment

Adjusted rateCertified registered nurse-midwives providing services in rural areas are paid at 112% of the established Medicaid fee schedule.

Payment limitPayment is the lower of usual and customary charges or 112% of the established Medicaid fee schedule.

Geographic scopeRural areas are outside Cache, Weber, Davis, Salt Lake, and Utah counties.

Rural Nurse Practitioner Rate Differential

Rural differentialA 12% rate differential is paid for nurse practitioner services rendered in rural Utah.

Charge limitationThe differential may not exceed usual and customary charges.

Rural Utah definitionRural Utah means areas outside Cache, Weber, Davis, Salt Lake, and Utah counties.

Case management payment must not duplicate payments made to public agencies or private entities under other program authorities for the same purpose. HPR case management may augment, but not supplant or duplicate, service coordination available through a recipient’s Plan or other community providers.

Services were limited to Medicaid-eligible individuals.
Direct and indirect administrative activities related to determining Medicaid eligibility were outside the scope of the service.

Billing Rule

Supervised Physician Assistant Billing

When a licensed physician assistant provides services while employed and working under supervision in a group practice, private office, community health center, or local health department, the supervising provider must bill for the service according to the supervising provider’s usual and customary fee schedule.

Applies to supervised physician assistant services in the specified practice settings.

Billing Rule

Independent Physician Assistant Billing

When a licensed physician assistant provides services in a private independent practice, the physician assistant must bill according to the physician assistant’s usual and customary fee schedule.

Applies to licensed physician assistants working in private independent practice.

Billing Rule

Dental Fee Schedule Billing

For dental services and dentures, payment is based on the established state-developed fee schedule unless a lesser amount is billed. The billed amount cannot exceed the provider’s usual and customary charges to private-pay patients.

The rates apply to governmental and private providers unless otherwise noted in the plan.
Rates are effective for services on or after the date listed on the Attachment 4.19-B Introduction Page.
Rates are published at http://health.utah.gov/medicaid/stplan/lookup/CoverageLookup.php.

Billing Rule

Enhanced Urban Dental Reimbursement

In urban counties, an eligible dental provider that signs an agreement to see 100 or more clients during the next year may receive reimbursement at the lesser of billed charges or 120% of the established fee schedule.

Urban counties: Cache, Weber, Davis, Salt Lake, and Utah.
State-funded clinics are excluded from this incentive.

Billing Rule

Enhanced Rural Dental Reimbursement

In rural counties, eligible dental providers, including state-funded clinics, may receive reimbursement at the lesser of billed charges or 120% of the established fee schedule.

Rural counties are counties other than the identified urban counties: Cache, Weber, Davis, Salt Lake, and Utah.

Billing Rule

Certified Nurse-Midwife Payment

Payments for licensed certified registered nurse-midwife services are based on the established fee schedule for selected HCPCS codes unless a lower amount is billed. The billed amount cannot exceed usual and customary charges to private-pay patients.

Selected HCPCS codes are established in compliance with HIPAA requirements.
Payment includes the physician’s collaboration fee for co-management of the case.

Billing Rule

Nurse Practitioner Direct Billing

Approved procedure codes may be directly billed by a licensed nurse practitioner. Payment for approved services is the lower of the usual and customary charge or the established physician fee schedule.

Physician fee schedule methodology is described in Section D, “Physicians,” Page 4 of Attachment 4.19-B.

Billing Rule

Audiology Fee Schedule Billing

Covered audiology services are paid according to the established fee schedule unless a lower amount is billed.

Fee schedule rates are the same for governmental and private providers unless otherwise noted in the plan.
Rates are published on the agency’s website at http://health.utah.gov/medicaid/.

Billing Rule

Supervised Nurse Practitioner Billing

When a licensed nurse practitioner provides services while employed and working under supervision in a group practice, private office, community health center, or local health department, the supervising provider must bill for the service according to the supervising provider’s usual and customary fee schedule.

Applies to supervised nurse practitioner services in the specified practice settings.

Billing Rule

Independent Nurse Practitioner Billing

When a licensed nurse practitioner provides services in a private independent practice, the nurse practitioner must bill according to the nurse practitioner’s usual and customary fee schedule.

Applies to licensed nurse practitioners working in private independent practice.

Organizational unitThe representatives are employed within the Bureau of Managed Health Care.

Urban Counties

Cache CountyIncluded among the urban counties.

Weber, Davis, and Salt Lake countiesIncluded among the urban counties.

Utah CountyIncluded among the urban counties.

Rural Areas

DefinitionRural areas, or rural Utah, are areas outside Cache, Weber, Davis, Salt Lake, and Utah counties.

Excluded county groupCache, Weber, Davis, Salt Lake, and Utah counties are excluded from the rural designation.

Rate-adjustment scopeThe rural designation is used for the certified nurse-midwife and nurse practitioner rate adjustments described in the policy.

Lesser-of Payment Rule

Billed amountPayment is limited to the amount actually billed when that amount is lower.

Fee schedule comparisonFor applicable services, payment is compared with the established fee schedule or established physician fee schedule.

Usual-and-customary comparisonFor applicable services, payment is also limited by the provider's usual and customary charge, including charges to private-pay patients.