Medical billing services in Utah

Billing in Utah: what's different

The rules below change how a claim is filed and paid in Utah. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.

Rules that change how Utah claims are billed

• The county decides whether a member must pick an ACO⁴

  DHHS requires members who live in Utah, Salt Lake, Davis, Weber, Box Elder, Cache, Iron, Morgan, Rich, Summit, Tooele, Wasatch or Washington County to choose a health plan from Health Choice Utah, Healthy U, Molina Healthcare or SelectHealth Community Care. Adult Expansion members in Davis, Salt Lake, Utah, Washington and Weber counties are required to enroll in a Utah Medicaid Integrated Care plan instead, mental health and substance use disorder services go to the prepaid mental health plan contractor for the county where the member lives, and children in CHIP sign up for Healthy U, Molina or SelectHealth with Premier Access for dental. A practice outside those counties bills fee-for-service.

• PRISM replaced the MMIS in April 2023 and ended paper claims³

  The Provider Reimbursement Information System for Medicaid handles provider enrollment, prior authorization, member eligibility, claims adjudication and claims payment for DHHS, and paper claims are no longer accepted. Since April 1, 2021 access has required multi-factor authentication, each approved provider assigns a Provider Account Administrator, and additional administrators register with the State of Utah through a Utah-ID account. The portal itself is at prism.health.utah.gov.

• ACO contracts carry a 30-day clean claim standard and a PRISM enrollment edit⁸

  Health Choice Utah adjudicates a clean claim, one that includes all information necessary for processing, within 30 days or less of receipt, using DHHS's definition of a clean claim as one that can be processed without additional information from the provider or a third party; claims needing medical necessity review or under fraud, waste and abuse investigation are not clean. Every provider rendering a service to a Medicaid member, fee-for-service or managed care, including ordering, referring and prescribing providers, must be enrolled with Utah Medicaid in PRISM before the date of service, and the plan denies claims from contracted providers who are not. The plan began operations in 2012 and is owned by University of Utah Health Plans.

• Four managed care authorities with four different clocks⁷

  CMS's 2024 state tables record the Choice of Health Care Delivery program, the ACOs, as a statewide 1915(b) program running since March 23, 1983 with its waiver approved through June 30, 2027; Medicaid enrollees are pre-assigned, have 15 to 45 days to choose depending on when the enrollment file posts, and can change plans within the first 90 days and during an annual open enrollment. Utah Medicaid Integrated Care runs region-specific under 1115(a) demonstration authority since January 1, 2020, the prepaid mental health plans under 1915(b) since July 1, 1991, dental under 1915(b) since September 1, 2013, transportation under 1902(a)(70) since July 12, 2001, and the voluntary UNI HOME plan for people with developmental disabilities under 1915(a) since July 1, 2011, with a waiting list.

• EVV data follows the claim, on a three-month clock⁹

  Utah's EVV page describes a system of telephonic, mobile and web-based verification inputs that electronically verifies a home or community based service visit, required for all personal care services and home health services under Medicaid. Providers are not required to use a specific software or vendor as long as the system meets the federal requirements, they submit EVV records to accompany each PCS or HHS claim within three months of submitting the claim, and providers who do not have EVV data are subject to recoupment or penalties. CMS's July 30, 2021 letter to the Division of Medicaid and Health Financing confirmed compliance for personal care services from July 1, 2021, supplementing its January 15, 2021 determination.

• Two insurers write about half of Utah's commercial health premium¹³

  The Utah Insurance Department's 2025 Health Insurance Market Report puts SelectHealth Inc at 36.9 percent of 2024 commercial health insurance premium and Regence BlueCross BlueShield of Utah at 12.1 percent, with Molina Healthcare of Utah, United Healthcare Insurance Company, Aetna Life, Humana, Cigna and University of Utah Health Insurance Plans among the other carriers drawing consumer complaints. Twelve domestic insurers covered about 86 percent of the state's major medical market, the individual market held 405,818 members, about 47 percent of that market, and about 73 percent of individual members were enrolled through the federal marketplace. For 2027 the department lists BridgeSpan, Imperial Health Plan of the Southwest, Molina (off exchange only), Regence, SelectHealth and University of Utah Health Insurance Plans as individual market insurers.

Services for Utah practices

Remitwright serves Utah practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.

• Medical billingClaims worked by one named biller
• CredentialingEnrollment, CAQH and PECOS kept current
• Eligibility verificationCoverage and benefits checked before visits
• Prior authorizationAuths requested, tracked, attached to claims
• Denial managementEvery denial read, worked and appealed
• A/R follow-upUnpaid claims chased before filing limits