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Utah Medicaid
Utah Medicaid, revalidated and paid
An active Utah Medicaid enrollment, a revalidation finished inside 60 days, and claims paid instead of held.
Utah Medicaid mails a revalidation letter to a provider's pay to address, and a provider that has not finished within 60 days gets a temporary payment hold, then termination at 90 days. The rule is the Provider Enrollment rule in the Utah Administrative Code, last changed November 10, 2023.
Revalidation cycle
Providers revalidate with Medicaid through PRISM at intervals not to exceed five years, depending on risk level. Utah Administrative Code, Provider Enrollment rule
Revalidation letter
The letter goes to the pay to address in PRISM; 60 days to finish or a temporary payment hold, and termination at 90 days. Utah Administrative Code, Provider Enrollment rule
After termination
Termination for any reason means reenrolling as a new provider; one terminated for missing revalidation may request a fair hearing. Utah Administrative Code, Provider Enrollment rule
Automatic closure
Missing the five year cycle, an expired license, or a year or more without billing and without notice can close the contract. Utah Administrative Code, Provider Enrollment rule
Unfinished applications
Online applications are purged after 90 days if they are not completed and submitted. Utah Medicaid, Become a Medicaid Provider
Payment withholding
Utah may withhold payments if requested information is not provided within 30 calendar days of a written request, after written notice. Utah Administrative Code, Utah Medicaid Program rule
What we see in practice
45 to 90 days from submission to an active Medicaid ID.
In the official words
…within 60 days from the date of the letter, or the Department will place a temporary payment hold on the provider account.
A provider terminated for any reason must reenroll and be approved as a new provider.
Utah starts a 60 day payment hold clock with one letter
An enrolled Utah Medicaid provider must revalidate through PRISM, the Provider Reimbursement Information System for Medicaid, at intervals not to exceed five years, depending on the provider's risk level. Utah Administrative Code, Provider Enrollment rule Utah Administrative Code, Provider Enrollment rule The Department notifies the provider with a letter mailed to the pay to address in PRISM. Utah Administrative Code, Provider Enrollment rule That leaves any provider whose pay to address is out of date exposed to a missed deadline.
The rule gives the provider 60 days from the date of the letter to finish, or the Department places a temporary payment hold on the provider account. Utah Administrative Code, Provider Enrollment rule A provider that fails to revalidate within 90 days from the date on the letter is terminated, with the option to request a fair hearing. Utah Administrative Code, Provider Enrollment rule Utah Administrative Code, Provider Enrollment rule
The rule was last changed on November 10, 2023, with a notice of continuation on September 16, 2024. Utah Administrative Code, Provider Enrollment rule Utah Administrative Code, Provider Enrollment rule It says it implements revalidation requirements set out in federal regulations. Utah Administrative Code, Provider Enrollment rule The federal floor under it is revalidation of every enrolled provider, whatever the provider type, at least every five years. 42 CFR 455.414
How enrollment works, step by step
- Create a Utah ID account. A provider registers with the State of Utah this way, and then goes through multi factor authentication to reach the application. Utah Medicaid, Become a Medicaid Provider Utah Medicaid, Become a Medicaid Provider
- Open the application. The same page sends new providers to PRISM to apply and to track the application. Utah Medicaid, Become a Medicaid Provider
- Finish and submit inside 90 days. Online applications are purged after 90 days if they are not completed and submitted. Utah Medicaid, Become a Medicaid Provider
- Fax supporting documents with the provider's name and National Provider Identifier (NPI). Utah's forms page, in a May 2020 note still posted, says documents may be faxed. Utah Medicaid, Provider Enrollment Forms Utah Medicaid, Provider Enrollment Forms
- Keep email free of patient data. Provider Enrollment asks that no protected health information be sent to its email address. Utah Medicaid, Become a Medicaid Provider
- Name more than one account administrator. Utah asks for the account administrator profile to be given to several employees, so the account stays managed if one leaves. Utah Medicaid, PRISM Portal Access Utah Medicaid, PRISM Portal Access
Utah reimburses only for services rendered during an enrollment period, Utah Administrative Code, Provider Enrollment rule so we schedule around 45 to 90 days from submission to an active Medicaid ID for a new Utah provider.
What the provider agreement and sanction rules add
By signing a provider agreement, a Utah provider agrees to follow the terms incorporated into it, including policies and procedures, provider manuals, Medicaid Information Bulletins and provider letters. Utah Administrative Code, Utah Medicaid Program rule Utah Medicaid publishes those bulletins and manuals on its official publications page. Utah Medicaid Official Publications
The sanction rule adds a documentation duty. A provider with a license restriction or probation that limits an age group or gender, or that requires supervision, must give the Department the same documents it gives the licensing body. Failing to do so is a basis for suspension or termination of Medicaid enrollment. Utah Administrative Code, Administrative Sanction Procedures rule
The same rule defines suspension as a status in which the Division of Professional Licensing, or an equivalent entity in another state, classifies a provider, and says it results in the Department not adjudicating or reimbursing claims from that provider. Utah Administrative Code, Administrative Sanction Procedures rule
Utah Medicaid tells a terminated provider to contact Provider Enrollment to request reenrollment. Utah Medicaid, PRISM Portal Access Utah Medicaid, PRISM Portal Access
Where Utah enrollments lose money
A provider that misses the 60 day mark gets a temporary payment hold, and one that misses 90 days is terminated. Utah Administrative Code, Provider Enrollment rule Utah Administrative Code, Provider Enrollment rule Utah then reimburses only for services rendered during an enrollment period, so claims for dates after termination are exposed. Utah Administrative Code, Provider Enrollment rule
A contract may also close automatically when the five year cycle is missed, when a professional license or a clinical laboratory improvement amendments license expires, or when a provider fails to bill Medicaid for one or more years without notification. Utah Administrative Code, Provider Enrollment rule Utah Administrative Code, Provider Enrollment rule Utah Administrative Code, Provider Enrollment rule Utah Administrative Code, Provider Enrollment rule
Payments can also be withheld from a provider that does not supply requested information within 30 calendar days of a written request, and the Department must give written notice first. Utah Administrative Code, Utah Medicaid Program rule Utah Administrative Code, Utah Medicaid Program rule
Utah no longer accepts paper claims since its April 2023 claims change to PRISM. Utah Medicaid, PRISM Utah Medicaid, PRISM Any paper claim received is securely destroyed and not returned to the provider or its vendor. Utah Medicaid, PRISM
Check where you stand before you submit
WeBill Health runs Revenue Velocity Credentialing with 24/7 CAQH and PECOS lifecycle monitoring, so revalidation dates and affiliation gaps are caught before they become suspended claims. Every file gets Human Expert Review from a credentialing specialist before it goes to the Utah Department of Health and Human Services.
Sources
- Utah Administrative Code, Provider Enrollment rule
- Utah Medicaid, Become a Medicaid Provider
- Utah Administrative Code, Utah Medicaid Program rule
- adminrules.utah.gov, 971
- medicaid.utah.gov, accessing prism
- medicaid.utah.gov, prism
- medicaid.utah.gov, provider enrollment
- medicaid.utah.gov, health care providers
- medicaid.utah.gov, utah medicaid official publications
- ecfr.gov, title 42.xml
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