New Choices – Providers

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Utah Medicaid Information Bulleting (MIB) and Provider Manuals

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Attachment A

Utah Medicaid Provider Enrollment Information opens in a new tab

NPI Application opens in a new tab

IRS W-9 Form opens in a new tab

Provider Checklist

Attachment B Forms for New Choices Waiver Provider Enrollment

IMPORTANT INSTRUCTIONS – READ CAREFULLY

Provider enrollment applications within PRISM are frequently returned for edit because providers did not upload or complete all of the required steps. To avoid this, we strongly encourage New Choices Waiver (NCW) providers to contact the NCW Provider Specialist before submitting or validating your PRISM record to verify all of the items needed. The NCW Provider Specialist can be reached at (801)538-6497.

All New Choices Waiver providers must complete an Attachment B that corresponds to the New Choices Waiver service(s) that the provider is qualified to provide and intends to offer. If the provider plans to offer more than one New Choices Waiver service, the provider must complete a separate Attachment B for each of the distinct services. Just the final (signature) page of each Attachment B must be uploaded to the provider’s file within the PRISM portal.

For Adult Residential Services providers including assisted living facilities, independent living facilities, community residential treatment facilities and small health care (Type N) facilities, if your facility offers more than one level of care it is important to complete a separate Attachment B for each/all of the residential levels of care that you are licensed or certified to provide. (For example, a licensed ALF with a secure memory care unit should complete an Attachment B for ALF Type 1 & 2 and a separate Attachment B for ALF secure memory care. Another example, a licensed ALF (non-memory care) that has a certified independent living wing should complete an Attachment B for ALF Type 1 & 2 and a separate Attachment B for certified independent living.)

For existing providers going through the validation process, it is very important that your PRISM provider enrollment file match up with existing New Choices Waiver provider enrollment records. Services that you have been approved to offer before now should be included in PRISM as well. If your PRISM file does not align with previously approved services, your application will be returned for edit. If you need to verify which service(s) your agency has signed up to offer through New Choices Waiver, please return to your provider file within the PRISM Portal and review this information in the section labeled “HCBS Waiver and EPAS.” An Attachment B must be submitted for each of the services listed there.

Adult Day Care S5102 – Att B opens in a new tab

Adult Residential Services – ALF Memory Care T2016 – Att B opens in a new tab

Adult Residential Services – ALF Type 1 & 2 and Type N T2031 – Att B opens in a new tab

Adult Residential Services – Certified Independent Living Facility H0043 – Att B opens in a new tab

Adult Residential Services – Licensed Community Residential Care T2033- Att B opens in a new tab

Assistive Technology Devices T2028 – Att B opens in a new tab

Attendant Care Services S5125 – Att B opens in a new tab

Caregiver Training S5115 – Att B opens in a new tab

Case Management Services T1016 and T2024 – Att B opens in a new tab

Chore Services S5120 – Att B opens in a new tab

Community Transition Services T2038 – Att B opens in a new tab

Consumer Preparation Services S5108 – Att B opens in a new tab

Environmental Access – Home Modifications S5165 – Att B opens in a new tab

Environmental Access – Vehicle Modifications T2039 – Att B opens in a new tab

Financial Management Services T2040 – Att B opens in a new tab

Habilitation Services T2017 – Att B opens in a new tab

Home Delivered Meals S5170 – Att B opens in a new tab

Homemaker Services S5130 – Att B opens in a new tab

Medication Admin – Med Reminder System S5185 – Att B opens in a new tab

Medication Admin – Med Set-Up and Admin H0034 – Att B opens in a new tab

Non-Medical Transportation T2003, S0215, T2004 – Att B opens in a new tab

Personal Budget Assistance H0038 – Att B opens in a new tab

Personal Emergency Response System S5160, S5161, and S5162 – Att B opens in a new tab

Respite Care – Hourly and Daily S5150 and S5151 – Att B opens in a new tab

Respite Care – Overnight, Out of Home, Room and Board Included H0045 – Att B opens in a new tab

Specialized Medical Equipment, Supplies & Supplements T2029 – Att B opens in a new tab

Supportive Maintenance T1021 – Att B opens in a new tab

Provider Billing

Provider Rates Effective July 1, 2017 opens in a new tab

Place of Service Codes opens in a new tab

Billing Info opens in a new tab

Medicaid Claims Link

UHIN Link opens in a new tab

PRISM Training Slides April 2014 (PDF) opens in a new tab

Provider Training

Provider Training opens in a new tab

NCW Incident Report Form opens in a new tab

NCW Incident Reporting Protocol opens in a new tab