Pharmacist Medicaid Provider

Pharmacist Provider Enrollment Cheat Sheet

  1. A Utah ID is required. If you have not yet set up a Utah ID, visit opens in a new tab
    1. Select the Create an account link on the web page
    2. Using a valid email address, follow the prompts for Utah ID creation
    3. For step-by-step instructions, please visit opens in a new tab and select Account Creation
  2. An NPI (National Provider Identifier) is required. If you have not yet signed up for an NPI, visit opens in a new tab
    1. Select Create a New Account
    2. Once you have created an account, you must fill out the application to request an NPI number
    3. NPI numbers should be assigned with 15 days of application
  3. Once you have a Utah ID and NPI number, go to
    1. On the page headings located at the top of the page, click Providers, in the drop down select, Become a Medicaid Provider which opens a page entitled Become a Medicaid Provider
      1. This page lists steps required to become a Medicaid provider
      2. Halfway down the page, you will see a heading-New Enrollment Application and Track Your Application section
        1. The first sentence under this heading states “To become a Utah Medicaid Provider or to track your application, click on the PRISM Portal.” The words PRISM Portal is the link to the PRISM Portal login.
        2. Click on the PRISM link on the web page (as described in prior step)
        3. To login to the PRISM Portal:
          1. Enter Utah ID (instructions for obtaining a Utah ID listed in Step 1)
          2. Enter password
          3. Multi-Factor Authentication (MFA) is required to login to PRISM Portal
            1. Instructions for MFA can be found on the Become a Medicaid Provider page or at this link opens in a new tab
      1. Once logged in to PRISM Portal, you must complete the New Provider Enrollment
        1. Click the New Enrollment link at the top of the page
          1. Enrollment Type page will open
            1. Individual/Sole Proprietor is selected by default
              1. Regular Individual/Sole Proprietor is selected by default
            2. Leave the defaulted selections as your selections and click the Submit button located at the bottom left of the webpage
          2. Basic Information/W9/Home Address pages will open
            1. Fill out all fields with an asterisk (*) which indicates it is a required field
            2. Within the Basic Information section, there is an Applicant Type drop down. You should select Ordering, Referring and Prescribing Only
              1. Ensure your email address is correct; an email will be sent for any needed correction
              2. Continue working through the W9 Information section, Home Address section and the Location Address Details, be sure to validate your address by clicking the Validate Address button placed after the zip code.
                1. If you have entered an invalid address, click OK and enter in the City, State and County in the boxes below “OTHER’ Click OK, OK
                  1. Click the Finish button at the bottom right of the webpage
                  2. Once you click the Finish button, you should receive a pop-up message listing your Application ID
                    1. Write down your Application ID so you can track your application.
              1. Enrollment Steps
                1. Basic Information Status should be completed
                  1. Complete each REQUIRED step; you may bypass any UNREQUIRED steps
                    1. Specialties
                      1. Click ADD and enter one of these 2 specialties
                        1. Suppliers, Pharmacist, No Subspecialty
                        2. Suppliers, Pharmacist, General Practice
                    2. Add Provider Controlling Interest/Ownership Details
                      1. Click ADD to add a Managing Employee
                        1. Type: Managing Employee
                          1. Enter the following required fields (indicated with *):
                            • Percentage Owned
                            • Social Security Number
                            • First Name
                            • Last Name
                            • Phone Number
                            • Date of Birth
                            • Start Date (Licensure Receipt)
                            • Address (validate address)
                        1. Click OK
                        2. Click Owner SSN/EIN/TIN
                          1. Scroll to the bottom of the page and click Final Adverse Legal Actions Convictions Disclosure link
                          2. Select Yes or No
                          3. Click OK
                          4. At the top Click Close
                    3. License (add professional license information) Click Close
                    4. Taxonomy Details
                      1. Enter one of the following:
                        1. 1835G0000X (Regular Individual/Sole Proprietor) or 183500000X
                    5. Complete Enrollment Checklist
                      1. Read through each questions answering Yes or No
                      2. After answering all the questions, click save at the top left of the screen, then click close
                        1. Upload Documents
                          1. Click the Required Documents to get the links for:
                            1. Provider Agreement for Medicaid

(If unable to complete digitally (using fill & sign options), please print out, fill out the document, and scan it in to be uploaded) opens in a new tab

  1. Fill out Page 1
  2. Sign and date Page 8
  1. Provider User Access Agreement

(If unable to complete digitally (using fill & sign options), please print out, fill out the document, and scan it in to be uploaded) opens in a new tab

  1. Section 1-User Information
    1. Be sure to add the Utah ID created in Step 1
  1. Section 2-C1 Access Information
    1. Domain Name is the Provider NPI
    2. Justification for Access should state New Enrollment
  1. Section 3 - Sign and Date
    1. Use link at the top of the page to sign and add initials where required (use fill and sign option to see the signing and initialing option)
  2. Section 4 -
    1. Needs to be initialed if you checked the box in Section 2 for Provider Security, Account Administrator
  3. Upload documents in Upload documents section
    1. Click ADD
    2. Document Type-Agreement
      1. Document Name-Provider Agreement (for Provider Agreement)
      2. Document Name-User Security Agreement (for User Security Agreement)
    3. Upload Professional License
      1. Click ADD
      2. Document Type-License
      3. Document Name-Professional License
      4. Click OK
      5. Check all documents are uploaded in the document list
      6. Close
        1. Submit the Enrollment
          1. Click next in the upper left-hand corner
          2. Terms and Conditions page will open
            1. Click Sign and Date
            2. Click Submit Application in upper right-hand corner
          3. You will receive a message stating Successful Enrollment
        2. You may now Track Application with the link at the top of the PRISM Portal
          1. PRISM Portal Main Page Provider Menu
            1. Track Enrollment Application link

Please contact the Utah Medicaid Provider Enrollment Team for assistance

Office: 1-800-662-9651 option 3, 4
Phone: 801-536-0471