Notice anything different? We’re making a big change to how we deliver your newsletter. Instead of the usual PDF, we’re transitioning to a more convenient email format. You’ll now find the latest updates, insights, and resources right in your inbox. |
WHAT'S IN THIS NEWSLETTER? |
Click on the section headings below to jump to a section. Note: navigation settings work best on a desktop. |
|
|
- BetterDoctor® Portal for Improved Provider Directory Accuracy
- Submitting Claims When Health Choice Utah Is the Secondary Payer
- Reporting Domestic Abuse, Neglect, and Exploitation
- Understanding Utilization Review and Coverage Decisions
- Oxygen Concentrator Coverage for Health Choice Utah Members
- Billing Guidelines for Monthly DME Medical Supplies
- Medicaid Pharmacy Changes Coming January 2026
- Medicaid Unlicensed Behavioral Health Providers
|
| - New Partnership Enhances Colorectal Cancer Screening Access
-
Protecting Members: Continued COVID-19 Coverage and Measles Mitigation
- Updated Clinical Practice Guidelines Now Available Online
|
- Codes Requiring Prior Authorization
|
|
|
BETTERDOCTOR® PORTAL FOR IMPROVED PROVIDER DIRECTORY ACCURACY |
To comply with the federal No Surprises Act and help patients find care easily, Health Choice Utah 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. |
SUBMITTING CLAIMS WHEN HEALTH CHOICE UTAH IS THE SECONDARY PAYER |
When Health Choice Utah 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.
|
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. |
|
|
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. Health Choice Utah 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.
|
|
|
OXYGEN CONCENTRATOR COVERAGE FOR HEALTH CHOICE UTAH MEMBERS |
Not all Health Choice Utah 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, Health Choice Utah is clarifying billing guidelines for monthly medical supplies. On August 11, 2025, Health Choice Utah 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. |
- Unlicensed providers, enrolled in PRISM, may continue billing through November 30, 2025.
-
All unlicensed providers (excluding Peer Support Specialists, Case Managers, and Behavioral Health Technicians) will be terminated in PRISM and Health Choice Utah as of November 30, 2025.
- Re-enrollment will not be permitted.
|
Peer Support Specialists, Case Managers, and Registered Behavioral Health Technicians: |
- Must submit proof of certification.
- Those who do not provide certification will be terminated effective November 30, 2025.
- Re-enrollment is allowed once proper documentation is submitted.
|
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. |
|
|
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.
|
PROTECTING MEMBERS: CONTINUED COVID-19 COVERAGE AND MEASLES MITIGATION |
Health Choice Utah 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. |
|
|
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. |
|
|
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. |
|
|
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. |
|
|
6056 Fashion Square Drive, Suite 3940, Murray, UT 84107 |
|
|
|
