Interoperability
Utah Medicaid has a new secure data sharing tool (FHIR API) to meet federal rules (CMS-0057-F). This tool allows health plans to safely share patient records, including billing claims, past doctor visits, approvals for care, and medical history. This helps patients keep their care on track when they switch health plans.
If you are an app developer, you must register your software to use this data exchange. Register your app through the Medicaid Payer Service portal.
For more information, visit:
To meet federal rules (CMS-0057-F), Utah Medicaid is launching a secure system to share patient information and provider directories. This system lets different health plans share a patient's medical history, doctor visits, and billing claims directly with doctors in our network. Sharing this data helps doctors coordinate care, but patients can choose to opt out at any time.
If you are an app developer, you must register your software to connect to this system. Register your app through the Utah Medicaid Vendor Service portal.
Interoperability Prior Authorization (ePA)
Utah Medicaid uses the Interoperability Prior Authorization (ePA) system to give you faster decisions on your requests. These requirements apply to all services you bill directly to Utah Medicaid.
Note: A prior authorization does not guarantee payment. You must still use correct coding (NCCI) and follow all Medicaid laws to be paid for services.
The ePA process is the same for both covered and non-covered services. Use the API to check requirements and submit requests in one place.
How to set up your access
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Register: Complete the provider registration process.
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Get credentials: After we approve your application, we will email your sandbox and production login details.
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Test: Complete testing in the sandbox to make sure your system connects correctly.
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Go live: Log in to the production site after your tests work.
System URLs:
How to request an ePA
Your Electronic Health Record (EHR) system will connect to the Medicaid API. This service helps you at three main points:
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When scheduling: Check if you need to take action before a patient visit.
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Before signing an order: See costs or coverage for meds, labs, or tests before you finalize the order.
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When sending an order: Use this when an order is sent to a lab or imaging center.
This Coverage Requirement Discovery (CRD) CDS hook service supports
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Appointment-book: Triggered when scheduling future patient visits to intervene with necessary pre-appointment actions or to determine scheduling.
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Order-sign: Occurs after a clinician selects, but before they sign, a new order, enabling decision support to provide details like cost or coverage for meds, labs, or procedures.
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Order-dispatch: Invoked when an order is sent to a fulfiller, often used in conjunction with "dispatched" status for, e.g., lab or imaging requests.
The system will respond with one of these messages:
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Prior authorization is not required.
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Prior authorization is required.
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An error has occurred.
If you get an error, call the Medicaid Policy Team at (801) 538-6155 (option 3, then option 3) or email [email protected].
Timeframes and decisions
Once you submit a request, you will hear from us within these times:
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72 hours for urgent (expedited) requests.
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7 calendar days for standard requests.
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Up to 14 calendar days if we need more information from you to make a decision.
Your response will show if the request is:
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Approved: Includes the date the approval ends.
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Denied: Includes the specific reason why it was denied or a request for more information from Medicaid.
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Requests for services that are not normally covered are reviewed one by one through the Medicaid exception process.
Requests for services that are not normally covered are reviewed one by one through the Medicaid exception process.
For more information, visit:
In accordance with the Patient Access and Interoperability final rule (CMS-9115-F), Utah Medicaid is implementing a Fast Healthcare Interoperability Resources (FHIR) standards-based solution to store, share, and retrieve Patient Access and Provider Directory Application Programming Interface (API) data. This solution will allow Medicaid members to have access to clinical, claims and other health data via third-party applications. Application developers will need to go to Vendor Service to register their application https://fp.medicaid.utah.gov/VendorService. opens in a new tab
For more information visit:
Vendors currently registered with Utah Medicaid
(Utah Medicaid does not endorse any specific vendor on the list below)