Members may receive Medication Therapy Management (MTM) or Comprehensive Medication Management (CMM) services, subject to the following requirements: 

Pharmacist eligibility

Pharmacists providing MTM or CMM services must:

• Be licensed as a pharmacist in the state of Utah
• Be enrolled as a provider with Utah Medicaid using an individual NPI number

Patient eligibility

Eligible patients must meet all of the following criteria:

• Be enrolled in Utah Medicaid (adult or pediatric)
• Be in an outpatient or ambulatory setting (not inpatient or long-term care)
• Not be eligible for Medicare Part D

• Be taking at least 3 medications to treat or prevent at least 1 chronic disease

Documentation requirements

Pharmacists must maintain documentation of the following:

• Patient information:

• • • Full legal name
    • Date of birth
    • Gender
    • Telephone number
    • Address
    • Current and past medical conditions
    • Allergies
    • Primary physician and contact information

• Encounter details:

• Date of appointment

• Time spent with the patient

• Complete medication list, including prescription and non-prescription drugs, vitamins, supplements, and herbal products

• Evaluation of the patient’s medication regimen, including concerns or drug-related problems as outlined in the Utah Medicaid Medication Therapy Management Encounter Guidance or Comprehensive Medication Management Services Encounter Guidance

• Written MTM/CMM plan (Patient/Provider Summary Report) that includes goals and action items to resolve identified therapy issues

• Confirmation that the MTM/CMM plan was delivered to the patient and applicable providers within 2 business days

• Evaluation of treatment plan outcomes

• Coordination and follow-up activities with the patient’s broader healthcare team

• All written and verbal communication must be documented in the patient’s record
• Documentation must be retained for 5 years

Requirements for covered services 

• The MTM or CMM encounter is conducted one-on-one with the patient or caregiver (e.g., caretaker relative, legal guardian, power of attorney, licensed health professional).
• Providers must be contacted by phone for interventions requiring immediate attention.

Limits

• Face-to-face: One initial encounter and up to 3 follow-up encounters for MTM and CMM services are covered per Medicaid member per calendar year.
• Telephonic: A total of 4 MTM and CMM services combined are covered per Medicaid member per calendar year.

Billing information

Fee for Service Medicaid

• Point of Sale claims: Billing details can be found on the Utah Medicaid NCPDP Payer Sheet.  

• Medical claims: Information on code rates and limits can be found using the Utah Medicaid Coverage Lookup Tool. 

 

• Contact for claims or inquiries: Call the Pharmacy Information Line at (801) 538-6155 (option 1, option 1).

 

CPT	Description	Rate	Limits
99605	Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, new patient.	53.48	Face-to-face: Four consults per patient per year, including one new patient service and 3 established patient services.
99606	Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, established patient.	32.94
99607	Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; each additional 15 minutes.	16.68
98012	Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, straightforward medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 10 minutes must be exceeded.	32.94	Audio-only: Four consults per patient per year.
98013	Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, low medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.	44.60
98014	Synchronous audio-only visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination, moderate medical decision making, and more than 10 minutes of medical discussion. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.	55.18

Utah managed care plans billing information

Please contact the specific plan if additional information is needed.

Health Choice

• MTM claims submission: Submit MTM claims through the medical benefit.
• Contract requirement: Pharmacies must have a medical contract to provide MTM services or obtain an out-of-network prior authorization.
• Request for participation: To contract with Health Choice Utah, submit the Request for Participation form to providers@healthchoiceutah.com.
• Prior authorization: Use the Medical Prior Authorization form.
• Electronic claims submission: Health Choice recommends submitting MTM medical claims electronically. Submission information can be found online.
• Accepted MTM CPT codes: 99605, 99606, 99607 on a HCFA claim form.
• Utah Medicaid requirement: All billing providers must be enrolled with Utah Medicaid.
• Contact for medical claims or MTM contract: Call the customer service line at (877) 358-8797.

Healthy U

• MTM claims submission: Submit MTM claims through the medical benefit.
• Contract requirement: Pharmacies must have a medical contract to provide MTM services.
• Contracting information: Email providercontracting@hsc.utah.edu or visit uhealthplan.utah.edu/providers/contracting-relations.
• Credentialing requirement: Complete a CAQH credentialing profile online. 
• Electronic claims submission: Healthy U recommends submitting MTM claims online. 
• Accepted MTM CPT codes: 99605, 99606, 99607 on a HCFA claim form.
• Utah Medicaid requirement: All billing providers must be enrolled with Utah Medicaid.
• Contact for medical claims or MTM contract: Call the Provider Contracting Office at (801) 587-2838 (option 4) or email providercontracting@hsc.utah.edu.

Molina

• MTM claims submission: Submit MTM claims through the medical benefit.
• Contract requirement: Pharmacies must have a medical contract to provide MTM services.
• Contracting information: Email MHUProviderContracting@molinahealthcare.com.
• Electronic claims submission: Molina recommends submitting MTM claims using the Availity Provider Portal.
• Accepted MTM CPT codes: 99605, 99606, 99607 on a HCFA claim form.
• Contact for medical claims or MTM contract: Call the Provider Contact Center at (855) 322-4081 or email MHUProviderServicesRequests@MolinaHealthcare.com.

Select Health

• MTM claims submission: Submit MTM claims through the medical benefit.
• Electronic claims submission: EDI information available at selecthealth.org/providers/claims/edi.
• Mail claims submission: Send to P.O. Box 30192, SLC, UT 84130.

Contact for claims or inquiries: Call the Member Services Team at (855) 442-3234.