Purpose of Medicaid Information Bulletin
Bulletins and Provider Manuals advise providers as to scopes
of service, policies, procedures and processes in the Utah
Medicaid Program for 'fee-for-service'
Medicaid clients. A fee-for-service Medicaid
client is defined as either
of the following:
client is not enrolled in a managed care plan (MCP);
client is enrolled in a managed care plan, but the service
that is needed is covered by Medicaid, not by the plan.
covered by Medicaid, instead of the managed care plan, vary
according to the individual contracts with managed care
plans. For example, some MCP contracts do not include
pharmacy and/or dental services. Medicaid refers to
services not covered in a contract with a MCP or Prepaid
Mental Health Plan as 'carve-out' services.
clients may receive covered services from any Medicaid provider. The provider
must follow Medicaid coverage and prior authorization requirements. The
provider submits the claim to and obtains payment from Medicaid. All questions
concerning services covered by Medicaid and not covered by the managed
care plan should be directed to Medicaid Information.
example, a Medicaid client enrolled in a MCP which does NOT cover pharmacy services
may receive pharmacy services from any Medicaid pharmacy provider.
rules apply to clients enrolled in the Medicaid Restricted Program. Restricted
Program clients are assigned to a Primary Care Physician or MCP, and
to a particular pharmacy. These clients must receive all health care services
through either the assigned provider or MCP, or receive a referral from those
providers, and all pharmacy services from the assigned pharmacy.
Care Plan Enrollees
contracts with managed health care organizations to provide medical and mental
health services to Medicaid clients. Each MCP and Prepaid Mental Health
Plan covers services as stated in the contract with Medicaid, and each has its
own procedures for services that require prior authorization. Each plan
may offer more benefits and/or fewer restrictions than the Medicaid scope of
enrolled in a MCP and/or a Prepaid Mental Health Plan (PMHP) must receive all
services covered by each plan through that plan. Providers must be affiliated
with the managed health care plan and follow its coverage and authorization
requirements. The provider obtains payment from the health care
questions concerning covered services and payment from a MCP must be directed
to the appropriate plan. A list of MCPs and PMHPs with which Medicaid
has contracts is included with your provider manual.
is critical for all providers to verify Medicaid coverage BEFORE services
are provided. Providers must know if the client is eligible for Medicaid
on the date of service, if the client is enrolled in a MCP, in a Prepaid Mental
Health Plan, in the Restriction Program, or has a Primary Care Provider.
This information is printed on the client's Medicaid card, and the information
is also available through Access Now and Medicaid Information.
Eligibility and MCP enrollment may change from month to month.
Medicaid staff make every effort to provide complete and accurate information
on all inquiries. However, because information regarding the plan the
client must use is available to providers, a claim will not be paid even if
the information given to a provider by Medicaid staff was incorrect.
and grievances concerning a MCP from either a client or
a provider must first go through the MCP's complaint process.
If the individual who initiated the complaint is not satisfied
with the MCP's final decision, he or she may then contact
the Division of Medicaid and Health Financing and request
refer to the Utah Medicaid Provider
SECTION 1, for more information about the following subjects:
managed care plans, Chapter 2
-Services available, Chapter 3
-Restriction Program, Chapter 3 - 2
-Verifying eligibility, Chapter 5