Utah Medicaid Pharmacy Program


Frequently Asked Questions

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Please choose your specific area of inquiry: General Questions | NCPDP File Layout | PDL+ | Provider/Prescriber Feed | Restriction

Any text highlighted in yellow has been added or updated since Monday, October 11, 2012.

General Questions

Can each ACO use alternatives that are less expensive?
Plans can create their own PDL, but they need to be primary rebatable or part of the State's list of covered non-rebatable drugs.

If the ACO receives COB information from sources other than the State of Utah, can it be used?
Yes, the health plan can be billed as a secondary.

Will there be changes to the 834?
Currently no changes have been planned.

How often does the State plan on changing the carve out drugs?
The State will review them quarterly. However, the PDL+ file feed, which includes the carve out drugs will be updated weekly.


NCPDP File Layout

What is the frequency of the file?
It varies by each ACO. Please contact Amy Allred for your specific schedule.

What is the file naming convention for the NCPDP File?
For Testing Files:
For Production Files:
The Company ID is the first 8 letters or your company name.

What is the file naming convention for the Response File?
For Production Files:
The Company ID is the first 8 letters or your company name.

Does reject record apply to the whole batch or just the record?
We'll only reject the record not the whole batch.

How will ACOs determine what was rejected?
The State will return a response file 2-3 business days after the NCPDP Post Adjudication File was uploaded. The State is using the telecom standard reject messages. Please review the file edits file prepared by the State for more information.

What value should be used for the Group ID Field
Please use the number the HMO uses with Medicaid.

What value should be used for the Patient ID.
Use the Medicaid ID and the HMO ID in the cardholder ID.

How should compound claims be handled?
Use the detail record and follow it with the compound record.

How does the compound information tie to the claim?
The prescription reference number



Where can I access this file?
You can access this through your PAUDO account that is hosted by GHS.

How often is this file updated?
After go live, this file will be updated on Thursdays.

Is it a full file for each update or just changes?
This will be a full file.

What is the fill layout or data dictionary for this feed?
Please download it from our project downloads.

Is there a predefined list of what the DME is?
The PDL+ will include what we have on file.


Provider/Prescriber Feed

Will the State provide the list of the pharmacies in their network?
Yes, it will be in the provider/prescriber feed. Utah Medicaid can not pay a claim to a provider not known to Medicaid.

When will the ACOs receive provider/prescriber feed?
One was sent out via email to the ACO project lead on August 22, 2012.

What are the qualifications for becoming a prescriber with the State?

Can a crosswalk be created on the encounter file to map NPI numbers to state Medicaid ID numbers?
Each ACO can check the provider/prescriber feed, which contains NPI.



Where is the restricted members list?
The 834 information currently sent to ACOs has the pharmacy and a primary physician restriction by patient.

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