Medication Therapy Management Services

Effective July 1, 2022, members may receive face-to-face Medication Therapy Management (MTM) services provided by a Medicaid enrolled pharmacist in an outpatient setting.

Pharmacist Eligibility

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

Patient Eligibility

  • Medicaid-enrolled adult and pediatric patients
  • Is in an outpatient setting (not inpatient or a long term care facility)
  • Is not eligible for Medicare Part D
  • Is taking at least 3 medications to treat or prevent at least 1 chronic disease

Documentation Requirements

  • Patient information must include:
    • Patient’s full, legal name
    • Date of birth
    • Gender
    • Telephone number
    • Address
    • Current and past medical conditions
    • Allergies
    • Primary physician and contact information
    • Date of appointment
    • Time spent with the patient
    • Medication list that includes all prescription and non-prescription medications, including vitamins, supplements, and herbal products
    • Overall evaluation of the patient’s medication regimen, as well as any specific concerns or drug-related problems outlined in the Utah Medicaid Medication Therapy Management Program Encounter Guidance opens in a new tab
    • Written plan (Patient/Provider MTM Summary Reports), including goals and actions, needed to resolve issues of current drug therapy, which will be provided to the patient and applicable provider within two business days of the encounter
    • Evaluation of success in meeting goals of medication treatment plan
    • Coordination, follow-up, and integration activities within the broader healthcare management services being provided to the patient
    • Providers must be contacted by phone for all interventions that require immediate attention, and all written and verbal communication must be documented in the patient’s MTM record
  • MTM Documentation shall be maintained for a period of five years

Requirements for Covered Services

  • The MTM encounter is conducted one-on-one with the patient or caregiver (e.g., caretaker relative, legal guardian, power of attorney, licensed health professional)
  • MTM encounters may be conducted face-to-face or telephonically

Limits

  • Face-to-face: one initial encounter and three follow-up encounters will be covered per Medicaid patient in 365 days
  • Telephonic: Four MTM consults per patient, per year

Encounter Limits

  • One initial encounter and three follow-up encounters will be covered per Medicaid patient in a 365-day period

Billing Information

Fee for Service Medicaid

For Point of Sale claims billing refer to the Utah Medicaid Pharmacy Resource Library NCPDP Payer sheets https://medicaid.utah.gov/pharmacy/resource-library/. For additional information you may contact the pharmacy team at 801-538-6155 - option 3, 3, 2.

CPT Code

Description

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

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

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

99441

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

99442

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

**

99443

Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

Billing information for the Utah Managed Care Plans

Please contact the specific plan if additional information is needed.

Health Choice

Pharmacies need to submit MTM claims for Health Choice Utah members through the medical benefit and have a medical contract to provide MTM services or an out-of-network prior authorization. Please use our Request for Participation form linked here https://healthchoiceutah.com/wp-content/uploads/mdocs/HCU_RequestForParticipationForm.pdf opens in a new taband email to providers@healthchoiceutah.com to request contracting with Health Choice Utah to provide MTM services. Upon receipt of the Request for Participation form, a Network Services Representative will reach out with additional information on the contracting process. Our Medical Prior Authorization form can be found at https://healthchoiceutah.com/providers/pa-guidelines/ opens in a new tab. Utah Medicaid requires all billing providers to be enrolled with Utah Medicaid as well.

Health Choice Utah recommends that pharmacies submit MTM medical claims electronically. Information on submission of electronic claims can be found at >https://healthchoiceutah.com/providers/edi/ opens in a new tab. We are accepting MTM CPTs 99605, 99606 and 99607 on a HCFA claim form.

If there are additional questions regarding medical claims or the finalized MTM contract, please call our Customer Service line at 1-877-358-8797.

Healthy U

Pharmacies need to submit MTM claims for Healthy U members through the medical benefit and have a medical contract to provide MTM services.

Healthy U recommends that pharmacies submit MTM medical claims online using our https://uhealthplan.utah.edu/providers/edi opens in a new tab. Please note: you must have a finalized contract and credentialing must be approved before you can submit a bill. We are accepting MTM CPTs 99605, 99606 and 99607 on a HCFA claim form.

If there are additional questions regarding medical claims or the finalized MTM contract, please call our Provider Contracting Office at 801-587-2838 option 4 or email providercontracting@hsc.utah.edu.

Molina

Pharmacies need to submit MTM claims for Molina members through the medical benefit and have a medical contract to provide MTM services. Please email MHUProviderContracting@molinahealthcare.com to contract with Molina to provide MTM services.

Molina recommends that pharmacies submit MTM medical claims online using our Availity Provider Portal opens in a new tab. Please note: you must have a finalized contract before you can create an Availity account.

If there are additional questions regarding medical claims or the finalized MTM contract, please call our Provider Contact Center at (855) 322-4081 or email MHUProviderServicesRequests@MolinaHealthcare.com.

SelectHealth

Pharmacies need to submit MTM claims for Select Health through the medical benefit. Claims may be submitted in two ways:

  1. Electronic Data Interchange (EDI) transactions https://selecthealth.org/providers/claims/edi opens in a new tab
  2. opens in a new tabU.S. Mail to:
    P.O. Box 30192
    SLC, UT 84130
    https://selecthealth.org/providers/claims opens in a new tab

If there are questions about submitting claims to Select Health please contact our member services team at 855-442-3234.