Home care billing · UT
Home care billing in Utah
Short answer
Home care billing in Utah splits by program: the accountable care organizations and the Utah Medicaid Integrated Care plans cover home health and private duty nursing for their members, while state plan personal care and the 1915(c) waiver services stay with Utah Medicaid fee-for-service through PRISM, which takes electronic claims only.
Agencies choose their own EVV vendor, and the EVV record has to follow each personal care or home health claim within three months or the payment is open to recoupment. DSPD waiver services start only after the provider accepts the Form 1056 authorization. A dedicated Remitwright biller keeps those steps in order, serving Utah agencies remotely. Rules for other states are on the home care billing by state page.
Last reviewed by the Remitwright billing team. Editorial policy
Key facts for Utah home care billing
| Fact | In Utah | Source |
|---|---|---|
| Programs that pay | Waiver for Individuals Age 65 or Older (0247.R07.00); New Choices Waiver (0439.R04.00); Physical Disabilities Waiver (0331.R06.00); Community Supports Waiver (0158.R08.00); Waiver for Technology Dependent, Medically Fragile Individuals (40183.R06.00) | 1 |
| How it is delivered | Split by benefit | 2 |
| EVV | Provider choice | 3 |
| Medicare home health and hospice | CGS Administrators, Jurisdiction 15 | 14 |
Programs that pay for home care in Utah1
Waiver for Individuals Age 65 or Older (0247.R07.00)
Adult day health, case management, homemaker, respite, enhanced state plan supportive maintenance home health aide services, adult companion, chore, personal attendant services, medication reminder systems, personal emergency response, supplemental meals, financial management and non-medical transportation, for people 65 and older who meet a nursing facility level of care.
New Choices Waiver (0439.R04.00)
Adult day care, case management, homemaker, respite, attendant care, chore, medication administration assistance, caregiver training, home delivered meals, community transition, adult residential services and related supports, for people 65 and older and people with physical or other disabilities ages 18 to 64 who meet a nursing facility level of care.
Physical Disabilities Waiver (0331.R06.00)
Personal attendant services, financial management services, personal emergency response systems, specialized medical equipment and supplies and non-medical transportation, for people 65 and older and people with physical disabilities ages 18 to 64 who meet a nursing facility level of care.
Community Supports Waiver (0158.R08.00)
Personal assistance, homemaker, respite, supported living, residential habilitation, day supports, supported employment, chore, companion, behavior consultation, family and individual training and related services, for people of any age with autism, intellectual or developmental disabilities who meet an ICF/IID level of care.
The Acquired Brain Injury (0292.R06.00), Community Transitions (1666.R01.00) and Limited Supports (1886.R01.00) waivers serve related populations with overlapping service lists, and Utah Medicaid's EVV page lists the DSPD attendant care, personal assistance, supported living, homemaker, chore, companion and respite codes that need EVV.
Waiver for Technology Dependent, Medically Fragile Individuals (40183.R06.00)
Personal attendant services, skilled nursing respite, extended home health aide, extended private duty nursing, financial management, family support and in-home feeding therapy, for people ages 0 to 20 who are medically fragile or technology dependent and meet a nursing facility level of care.
The Medically Complex Children's Waiver (1246.R02.00) provides personal attendant services, skilled nursing and routine respite and financial management services to medically fragile children ages 0 to 19.
How the program is delivered
Split by benefit. In CMS's 2024 program tables, Utah's accountable care organization program (Choice of Health Care Delivery), Utah Medicaid Integrated Care and the HOME program cover home health and private duty nursing, but none of Utah's managed care programs covers state plan personal care or HCBS waiver services, so those are billed to Utah Medicaid fee-for-service.2 Health Choice Utah, one of the accountable care organizations, lists home health and hospice among the services it covers, so a home health agency may bill an ACO for one member and Utah Medicaid for the next. Fee-for-service claims go through PRISM.
Electronic visit verification
Provider choice. Utah Medicaid requires EVV for all personal care and home health services, names no required software or vendor as long as the system meets the Cures Act requirements, and has each provider submit EVV records to accompany every personal care or home health claim within three months of submitting the claim; providers without EVV data are subject to recoupment or penalties.3 Under R414-522 the record is required for personal care from July 1, 2021 and for home health care services from January 1, 2023, under the state plan or a waiver, wherever the service needs an in-home visit, and it carries the date the record was created as well as the six Cures Act elements. Following CMS guidance, a caregiver who lives with the person served does not log an in-home visit, and equipment drop-offs are not in-home visits. CMS accepted Utah's personal care attestation for services from July 1, 2021 and its home health attestation on January 8, 2024.
Services under EVV3
- Home health nursing, aide and therapy visits in the home
- Personal care, including attendant care, personal assistance, homemaker, chore, companion and respite
- DSPD attendant care, personal assistance and supported living, provider-based or self-administered
Authorizations
Through the person-centered support plan for DSPD services. A support coordinator facilitates the planning meeting and submits a request for services through the division's case management system, which must be approved before the person-centered support plan is finalized, and the provider must accept the Purchase Service Authorization Form 1056 in that system before providing a service.6 R539-2-5 has the team meet at least once in each 12-month period from the planning meeting, and a budget change other than a budget-neutral one needs its own approved request. Medicaid home health works differently: under R414-14-4 an agency may make the initial assessment visit without prior authorization, but care after that visit must be prior authorized from the plan of care the agency submits, and R414-14-5 requires a new request whenever the level of service changes.
Where the claims go
Electronically, through PRISM. Since R414-24-3 took effect on April 3, 2023, Utah Medicaid no longer processes paper claims, and providers and their clearinghouses submit as an X12 HIPAA claim transaction, by direct data entry or as a web batch uploaded directly to PRISM.10 The EVV record for each personal care or home health claim must follow within three months of submitting the claim. For an ACO member's home health the plan's own rules apply: Health Choice Utah wants claims within the provider agreement's window or, if none is set, within 12 months of the date of service, wants secondary claims within 30 days of the primary payer's explanation of payment, and writes off late claims without billing the member.
Medicare home health and hospice in Utah
Medicare home health and hospice claims from Utah agencies go to CGS Administrators, which holds that work for Jurisdiction 15 across fifteen states and the District of Columbia, from Colorado and Wyoming to Pennsylvania and Virginia, even though its own Part A and Part B jurisdiction is Kentucky and Ohio.14 For Medicaid, R414-14-4 requires a member under a physician's care, the attending physician's orders and certification, a plan of care the physician and agency review and sign at least every 60 days, and the face-to-face requirement in R414-1-30, without which the Department may deny or recover payment; R414-14-5 allows only one home health provider for a member in any period and limits supportive maintenance care to time equal to one visit a day. CMS lists Utah compliant with home health EVV as of January 1, 2024.
Common rejections in Utah, and the fix
Payment recovered because the EVV record never followed the claim
The fixUtah Medicaid wants the EVV record within three months of submitting each personal care or home health claim, and providers without EVV data face recoupment or penalties. The biller ties each paid claim to its EVV file and sends the files to Utah Medicaid securely well inside the three months.
EVV record missing a required element
The fixR414-522 lists seven elements: type of service, the person served, date, location, the worker, begin and end times and the date the record was created. The biller checks the agency's export for every field before the file goes out and corrects records under the state's correction guidance.
Home health care billed past the initial visit without prior authorization
The fixOnly the initial assessment visit is exempt; every later visit, supply and therapy has to be in the plan of care submitted for prior authorization, and a change in the level of service needs a new request. The biller holds visits that fall outside the current authorization and files the new request first.
Second home health agency denied for the same member
The fixR414-14-5 allows one home health provider per member in any period, and the Department denies a second agency that asks for approval. The biller checks for an existing provider at intake and, where a subcontractor is used, keeps billing with the original agency only.
Payment recovered for a missing face-to-face encounter
The fixR414-14-4 lets the Department deny or recover home health payment when the face-to-face requirement in R414-1-30 is not met. The biller confirms the encounter documentation is in the chart before the first claim of an episode.
DSPD service delivered before the Form 1056 was accepted
The fixR539-2-6 requires the provider to accept the Purchase Service Authorization Form 1056 in the division's case management system before providing a service. The biller confirms acceptance for each person and service before the first visit is billed.
Paper claim sent to Utah Medicaid
The fixR414-24-3 ended paper claims in April 2023. The biller submits through an X12 transaction, direct data entry or a PRISM web batch and checks that PRISM accepted the claim.
Waiver or personal care claim sent to the ACO
The fixThe managed care programs cover home health and private duty nursing but not state plan personal care or HCBS waiver services. The biller routes those claims to Utah Medicaid fee-for-service and sends only plan-covered home health to the member's ACO.
Remitwright serves Utah home care and home health agencies remotely, inside the agency software you already use, with a dedicated biller.
FAQ
Questions from Utah agencies
Does Utah make us use a particular EVV vendor?
When do we send EVV records for a Utah claim?
Is waiver care paid by the ACO or fee-for-service?
Who authorizes DSPD waiver services?
Can we still send paper claims to Utah Medicaid?
Which Medicare contractor pays our home health and hospice claims in Utah?
Which programs pay for home care in Utah?
Which services fall under EVV in Utah?
Where do Utah home care claims go?
What do you need from us to start billing our Utah agency?
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