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WHAT'S IN THIS NEWSLETTER? |
Click on the section headings below to jump to a section. Note: navigation settings work best on a desktop. |
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- 2025 Legislative Session Summary
- Network Service Representative
Territory Map - Reminder: Always Verify Medicaid Eligibility
- Medicaid Formulary Changes Coming January 2026
- New Benefit Coverage: Refraction Eye Exam and Salpingectomy
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- Complex Case Management Services and Referral Options
- New Partnership Enhances Colorectal Cancer Screening Access
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How You Can Help Improve Members' Glycemic Status
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| - Controlled Substance Database (CSD)
and Opioid Prescribing Guidelines - Pharmacy Resources
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- Codes Requiring Prior Authorization
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2025 LEGISLATIVE SESSION SUMMARY |
We encourage you to review and consider how these bills may affect your operations, documentation, or clinical workflows: |
- HB281: Health Curriculum & Procedures Amendments - Requires schools to obtain parental consent before students receive certain health services. If you work with school-based services, you should be aware of these requirements and changes.
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HB452: Artificial Intelligence Amendments - Regulates the use of AI-powered mental health tools, including chatbots. Prohibits sharing individually identifiable health data and requires developers to file policies with the state. Mental health providers using AI tools should review compliance obligations.
- SB65: Medication-Assisted Treatment Amendments - Supports and regulates the use of medication-assisted treatment (MAT) in residential and recovery settings. Clarifies definitions and ensures MAT is in appropriate behavioral health programs.
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NETWORK SERVICE REPRESENTATIVE TERRITORY MAP |
Network Service Representatives assist our providers and hospitals with contracting, demographic updates, credentialing, and claims concerns, and serve as providers’ primary point of contact with Health Choice Utah. The map on the right shows our representatives and the areas they serve. |
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REMINDER: ALWAYS VERIFY MEDICAID ELIGIBILITY |
Member eligibility for Medicaid can change monthly, or even mid-month. Be sure to verify eligibility within 10 days of each visit. PRISM is the preferred verification tool. If you notice discrepancies between PRISM and your records, please email us at hcu@healthchoiceutah.com or call 877-358-8797. |
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MEDICAID FORMULARY CHANGES COMING JANUARY 2026 |
Starting January 1, 2026, Medicaid managed care plans are required to align certain drug classes with the Utah Medicaid Preferred Drug List (PDL). This change affects prior authorization, clinical criteria, and may require some members to transition to preferred medications. A 90-day transition period will be provided for impacted members. |
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NEW BENEFIT COVERAGE: REFRACTION EYE EXAM & SALPINGECTOMY |
Refraction Eye Exam: Effective May 1, 2025. Determination of refractive state (CPT code 92015) will be covered once per rolling year in addition to the other covered eye exam codes.
Salpingectomy: Effective May 1, 2025. Salpingectomy is covered for female sterilization. Prior authorization is not required, but to ensure correct claims processing, the Sterlization Consent Form must be completed and sent with the claim. This form must be completed at least 30 days, but not more than 180 days, prior to the date of sterilization except in the case of premature delivery or emergency abdominal surgery.
Use the following CPT codes to report this service: |
- 58661 - Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
- 58700 - Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
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COMPLEX CASE MANAGEMENT SERVICES AND REFERRAL OPTIONS |
Have you used our care management programs for complex and chronic condition management? Our programs offer: |
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Personalized support from registered nurses and licensed clinical social workers
- Education, advocacy, and coordination of healthcare services
- Collaboration with treating providers and primary care physicians (PCPs)
- No out-of-pocket cost for eligible members
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To refer a patient, contact us at 877-358-8797 |
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NEW PARTNERSHIP ENHANCES COLORECTAL CANCER SCREENING ACCESS |
Health Choice Utah has partnered with Previon Inc. to offer mail-delivered FIT (Fecal Immunochemical Test) kits, making colorectal cancer screening more accessible and convenient for members. This initiative supports the One Utah Health Collaborative’s goal of improving statewide health outcomes by removing common barriers to screening and encouraging early detection. Implementation is underway, and we hope to begin engaging our health plan members to receive FIT tests by mail in November.
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HOW PROVIDERS CAN HELP IMPROVE DIABETIC MEMBERS' GLYCEMIC STATUS |
Recent quality scores show there’s still room to improve glycemic status for members with diabetes. Routine A1c testing—along with proper documentation and coding—helps drive better care and outcomes. See this year’s performance and how you can help. |
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UTAH CONTROLLED SUBSTANCE DATABASE AND OPIOID PRESCRIBING GUIDELINES |
The Utah Controlled Substance Database program (CSD) is a prescription monitoring program that helps identify potential cases of drug abuse and over-prescribing. However, many prescribers are not using this valuable resource. Remember to check the database before prescribing for the first time. And if you're prescribing opioids, consider following these evidence-based interventions to help lower overdose death rates. |
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Our medication and pharmacy information is updated regularly. Because we may add or remove drugs from the formulary during the year, we recommend reviewing our website at least once per quarter to see the most recent information.
To help you know where to go, we compiled a webpage of pharmacy resources that might be helpful to you, including a link to our formularies, prior authorization forms, and more. |
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CODES REQUIRING PRIOR AUTHORIZATION |
We regularly review our list of Codes Requiring Prior Authorization and update it as changes occur, including removing codes no longer requiring authorization. Please search this list before scheduling procedures or prescribing durable medical equipment to determine if prior authorization is required.
Also take a moment to view Upcoming Changes to Codes Requiring Prior Authorization to ensure your authorizations for future procedures are also compliant. |
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Please share this newsletter with providers and staff in your office, and encourage them to subscribe to receive notifications when new editions are available. Past newsletters can be viewed here. |
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6056 Fashion Square Drive, Suite 3940, Murray, UT 84107 |
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