Frequently Asked Questions

Q: How do I know if a code requires prior authorization?
A: From the Coverage and Reimbursement Lookup Tool, choose the correct provider type, enter the code that is being requested, and the date that the service will be provided. If the code has age or quantity limitations or requires prior authorization, it will be listed under the Traditional column.

Or you can send an email to: medicaidcriteria@utah.gov. Please make sure to include the CPT/HCPCS codes for the criteria that you are requesting, the provider type, and also the type of coverage (Traditional). Please do not send any protected health information (PHI) through unsecured email and allow a 24-hour response time for criteria requests

Q: What do I need to send in with my request?
A: Please submit all supporting documentation that is required in the criteria for the service that is being requested directly to the request in PRISM.

Q: Where can I find the criteria for the service that I am requesting?
A: Criteria for medical/surgical procedures, imaging, and durable medical equipment can be found on the Utah Medicaid Criteria page, as well as some dental, therapies, and education criteria. Criteria that are not found in the drop down menus can be found in the appropriate provider manual for the service that is being requested, as well as in code specific "special notes" on the Coverage and Reimbursement Lookup Tool.

For a copy of criteria that is not found on the website, please call the prior authorization staff at (801) 538-6155, option 3, option 3, and then choose the appropriate program.

You may also send an email, including the CPT/HCPCS codes, the provider type, and the type of coverage (Traditional) to: medicaidcriteria@utah.gov. Please do not send any PHI through unsecured email and allow a 24-hour response time for criteria requests.

Q: How do I know if my request was received?
A: You may check the status of your request directly in PRISM. Locate the PA Request list, filter by member ID or tracking number. You will only be able to view requests associated with your submitting NPI. If you have additional questions not available through PRISM, please call the prior authorization staff at (801) 538-6155, option 3, option 3, and then choose the appropriate program. Be prepared with your Provider NPI/API number (if applicable), the name and Medicaid ID of the member.

Q: Can you pull this request (out of order) and process it?
A: We do have the ability to process urgent requests, out of order. If the request that was submitted is urgent, and should not be processed in the order that it was received, please call the prior authorization staff at (801) 538-6155, option 3, option 3, and then choose the appropriate program. Information regarding the urgent nature of the need must be identified. Please note that conditions that are considered medically emergent (ie. D&C’s for fetal demise) are not expected to receive authorization prior to the procedure being performed but should be submitted as soon as possible and will not be reimbursed until authorization is approved. If you have questions regarding this policy, please contact the prior authorization staff and be prepared with your Provider NPI/API number (if applicable), the name and Medicaid ID of the member.

Q: Where do I get a Prior Authorization Request Form?
A: The required forms can be found on the Utah Medicaid website, under Health Care Providers, Prior Authorization, Forms . Only current copies of Utah Medicaid forms will be accepted, all other forms will be returned without being processed. All requests must be submitted directly through PRISM portal unless otherwise approved.

Q: How do I get a password to see the Criteria?
A: Follow the instructions found on the Utah Medicaid website, under Health Care Providers, Prior Authorization, Criteria.

Q: Are services ever authorized retroactively?
A: Yes. Services can be authorized after they have been provided if the service was provided in a medically emergent situation or if Medicaid eligibility is approved after the date that the service is provided and the eligibility is post-dated back to the date of service, the request will be reviewed as if it were submitted prior to the service being provided and is still reviewed using the appropriate criteria.

Q: Is our patient eligible for Medicaid?
A: Eligibility can be verified by calling the Access Now Line at (801) 538-6155 by using the Eligibility Lookup Tool, or by using the Member Eligibility Inquiry in PRISM.

Q: How do I know which fax box to use?
A: Documentation should be uploaded directly to the tracking number in PRISM. The numbers to fax requests to can be located on the top of all forms located under Prior Authorization Request Form.

Q: I already received a prior authorization but the code that I asked for is not the code that I needed?
A: Please submit a Utah Medicaid Prior Authorization Modification Request Form and attach to existing tracking number in PRISM Please include an explanation of why the change in codes is needed, and all supporting clinical documentation.