Utah Medicaid Criteria

Prior authorization is required for certain covered services to document the medical necessity for those services. To determine if a procedure code requires prior authorization, access the Coverage and Reimbursement Lookup Tool. The All Providers General Information​ Section I Provider Manual provides detailed instructions regarding the prior authorization process and procedures.

To obtain a prior authorization, complete the current form for the service you are requesting and fax it to the appropriate fax number, as shown on the Prior Authorization Request Form.

The Medicaid agency’s decision to authorize, modify, or deny a given request is based on medical reasonableness, necessity, InterQual Criteria, and/or Utah Department of Health customized criteria, and local policy. Code-specific criteria can be found in the Coverage and Reimbursement Lookup Tool. Program-specific coverage information can be found in the corresponding provider manual for the service/item that is being requested.

General Prior Authorizations

When sending prior authorization requests, please include any relevant medical documentation pertinent to the requested service(s) that may include, but is not limited to the following:

  • Justification of medical necessity
  • H&P and/or other relevant clinical documentation
  • Conservative treatment history specific for length of time (e.g. activity modification, physical therapy, external support)
  • Associated medications with duration and outcome (e.g. NSAID trial, corticosteroid injections, oral contraceptives)
  • Previous treatments, therapies, diagnostic studies; include the relation, duration, and outcome (e.g. lab, imaging, and ablation)
  • If a patient has a known contraindication to above medications and/or treatments, include contraindication in documentation (e.g. allergic to NSAIDs, history of breast cancer so cannot take oral contraceptive pills, unable to obtain MRI due to pacemaker)

Outpatient Therapies

  • In addition to other required documentation, please include previous therapy visit notes showing what progress the patient has made when asking for additional therapy visits (physical, occupational, and speech).

Medical Supplies

  • In addition to the relevant items from above, a current physician’s order is required for DME and medical supplies.

Wheelchairs

  • In addition to other supporting documentation the following are required: a current physician’s order, a seating evaluation, the Wheelchair Training Checklist, documentation of medical necessity, and documentation showing the requested item is the least costly alternative.
  • Wheelchairs and associated accessories which require prior authorization and have no published clinical criteria are reviewed using InterQual criteria, when available. If InterQual criteria does not exist for the item requested, the request will be reviewed on a case by case basis by Department medical staff.
  • Refer to the Medical Supplies Manual and the Coverage and Reimbursement Look-up Tool for basic criteria.

Federally Required Forms

  • Any request for a Medicaid covered service that has a federal/state requirement, for consent or acknowledgment, must include the appropriate completed form. Federally required forms include, but are not limited to:
    • Consent for Sterilization
    • Utah Medicaid Hysterectomy Acknowledgment Form
    • Abortion Acknowledgment and Certification Form

The prior authorization reviewer may request additional documentation to establish medical necessity for the service(s) being requested.

For questions, please call the Prior Authorization Unit at (801) 538-6155, option 3, option 3, and then choose the appropriate program, or send an e-mail to: medicaidcriteria@utah.gov. If you have technical questions, contact the webmaster or call Medicaid Information at (801) 538-6155 or 1-800-662-9651.

Important links below

Coverage and Reimbursement Lookup Tool
Interqual Criteria Version Effective Dates
InterQual Transparency - Cloud
Medicaid Forms
Utah Medicaid Provider Manuals
Utah Medicaid Transplant Criteria