NOVEMBER 2025

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WHAT'S IN THIS NEWSLETTER?

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BETTERDOCTOR® PORTAL FOR IMPROVED PROVIDER DIRECTORY ACCURACY

To comply with the federal No Surprises Act and help patients find care easily, University of Utah Health Plans uses the BetterDoctor® portal to verify provider directory information every 90 days. You’ll be contacted by fax, mail, email, or phone to confirm or update your details. Accurate listings reduce barriers to care and ensure compliance.

U HEALTH PLUS NETWORK IS DISTINCT – IMPORTANT REMINDER FOR PROVIDERS

The U Health Plus network is distinct from the Healthy Preferred and Healthy Premier networks.

Participation in the Healthy Preferred or Healthy Premier networks does not automatically include participation in the U Health Plus network.

Providers should ensure their office staff are verifying network participation when scheduling or billing for members enrolled in U Health Plus plans. By staying informed and double-checking network status, providers can help ensure a smooth experience for members and avoid unnecessary claim issues.

SUBMITTING CLAIMS WHEN U OF U HEALTH PLANS IS THE SECONDARY PAYER

When University of Utah Health Plans is the secondary payer, complete and accurate claims submission is essential to prevent processing delays or denials. Claims must include all applicable Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) from the primary EOB. Missing RARC codes will result in denials with Claim Level Remark Code N4. Corrected claims must include the appropriate claim indicator, original claim number, and all CARC/RARC codes.

UNDERSTANDING AND NAVIGATING PRIOR AUTHORIZATIONS AND APPEALS

In September, the Provider Relations team hosted a webinar titled Understanding and Navigating Prior Authorizations and Appeals.

As a reminder, if a service requires prior authorization and one was not obtained, the service will be denied and considered a provider write-off. Submitting records with an appeal will not overturn the denial unless mitigating circumstances—such as a power outage or natural disaster—reasonably prevented the provider from obtaining authorization.

For more information, visit the Prior Authorizations webpage for guidance and resources.

REPORTING DOMESTIC ABUSE, NEGLECT, AND EXPLOITATION

Domestic abuse, neglect, and exploitation often rise during the holidays. Under Utah law, healthcare providers are required to report suspected cases involving children, elderly, or disabled adults. Educating your staff on how to recognize and report these incidents is critical to protecting vulnerable individuals.

VISION COVERAGE SUMMARY FOR CHIP

CHIP covers routine eye exams for children but does not cover eyeglasses, contact lenses, or elective vision correction surgeries like LASIK. While Medicaid does cover eyeglasses or contact lenses for vision correction, CHIP does not follow Utah Medicaid guidelines and does not reimburse based on the Utah Medicaid Coverage and Reimbursement Lookup Tool. 

PROVIDER OR PRACTICE CHANGES? START HERE

Keeping your provider information current is essential for smooth operations and accurate directory listings. Here’s how to ensure your practice details are up to date:

☑️ ADDING A NEW PROVIDER?  
Use our streamlined form to add a new provider to your practice: Add a New Provider to Your Practice 

☑️ NEED TO UPDATE PRACTICE INFO, ADD A LOCATION, OR TERMINATE ONE? 
Submit changes quickly using this form: Provider Update Form  

Keeping your information accurate helps us serve you—and your patients—better!

UNDERSTANDING UTILIZATION REVIEW AND COVERAGE DECISIONS

All utilization review decisions and care management actions are based on the appropriateness of care and services in accordance with the member’s benefit coverage. University of Utah Health Plans does not provide incentives or rewards for issuing coverage denials. Incentives are not used to create barriers to care or services. Utilization review decisions are made using nationally recognized criteria, plan benefits, and adherence to utilization management policies and procedures.

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NEW PARTNERSHIP ENHANCES COLORECTAL CANCER SCREENING ACCESS

University of Utah Health Plans 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.

PROTECTING MEMBERS: CONTINUED COVID-19 COVERAGE AND MEASLES MITIGATION

U of U Health Plans continues to cover COVID-19 vaccinations for adults and children as a routine immunization benefit. Members can receive vaccines at participating pharmacies without a prescription or provider order. With measles cases on the rise in Utah, MMR vaccination is also covered for infants 6 months and older when indicated.

UPDATED CLINICAL PRACTICE GUIDELINES NOW AVAILABLE ONLINE

We’ve recently updated our Clinical Practice Guidelines (CPGs) based on the latest scientific evidence. Where evidence is lacking, the guidelines are informed by a consensus panel of experts. These guidelines serve as valuable tools to help clinicians and members make informed, collaborative decisions about appropriate care for specific medical and behavioral health conditions. Our Quality Improvement Advisory Council has vetted the guidelines.

Click through the link provided to access the CPGs. 

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OXYGEN CONCENTRATOR COVERAGE FOR HEALTHY U MEMBERS 

Not all Healthy U members are limited to one Durable Medical Equipment (DME) supplier for oxygen concentrators in Utah. Coverage varies by county, and multiple contracted providers may be available.

BILLING GUIDELINES FOR MONTHLY DME MEDICAL SUPPLIES

In order to avoid denials, Healthy U is clarifying billing guidelines for monthly medical supplies. On August 11, 2025, Healthy U started applying the following logic:

Medical supplies filled on a monthly basis may be refilled between days 25 and 30 to ensure uninterrupted access for the member. This early refill window is intended to prevent supply shortages and does not authorize providers to duplicate supplies for the same dates of service.

MEDICAID PHARMACY 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.

MEDICAID UNLICENSED BEHAVIORAL HEALTH PROVIDERS

As announced in the September 2025 MIB, Medicaid will no longer allow unlicensed behavioral health providers to enroll in PRISM or submit the Unlicensed Mental Health and Substance Use Disorder Providers’ Form, effective September 1, 2025.

For Healthy U Medicaid:  

Peer Support Specialists, Case Managers, and Registered Behavioral Health Technicians: 

Modifier Guidance: Services rendered by unlicensed providers can be billed under the supervising clinician using the HL modifier as of September 1, 2025; however, its use will not be required until December 1, 2025. During this transition period, no claims should be rejected based on whether the HL modifier is included or excluded.

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PHARMACY RESOURCES

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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MEDICAL POLICY UPDATES

Medical policies for the following services have been recently created, revised, or archived: 

REIMBURSEMENT POLICY UPDATES

Reimbursement policies for the following services have been recently created or archived: 

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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