Utah UT

Utah DHHS Medicaid publishes PA requirements in FOUR layers, all on its own terms: (1) MEDICAL criteria are LICENSED INTERQUAL (UT does not author medical-necessity criteria itself) — an InterQual go-live/version-effective-dates PDF plus an InterQual Transparency cloud tool (elt.medicaid.utah.gov/transparencytool) name which InterQual modules/versions are in force. (2) PHARMACY criteria are state-authored per-drug/per-class PA PDFs — 128 documents under medicaid-documents.dhhs.utah.gov/pharmacy/priorauthorization/pdf/, predictable URL pattern, one PDF per drug or therapeutic class. (3) PER-SERVICE coverage/PA rules live in the Utah Medicaid Provider Manuals (publications directory) — All Providers General Information Section I is the master, then service-specific manuals. (4) CODE-LEVEL PA flags via the PRISM Coverage and Reimbursement Code Lookup Tool (health.utah.gov/stplan/lookup/CoverageLookup.php) and binding rules in Utah Admin Code R414 (rules.utah.gov, e.g. R414-10a transplant criteria). AUTHORITY: DHHS Medicaid (FFS) authors pharmacy criteria + provider manuals; medical necessity is delegated to InterQual. Managed care via 4 provider-led ACOs (Healthy U, Molina, SelectHealth Community Care, Health Choice Utah) that ride the same FFS criteria floor. BH carved out to 13 county PMHPs. No bot-wall; documents fetched cleanly via in-page chromium fetch from medicaid-documents.dhhs.utah.gov.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: 2011 (ACO model adoption) – ACOs admitted by contract date: SelectHealth 1995, Molina 1997, Healthy U 1998, Health Choice 2012-04-01. Next due: 2027-07-01 (RFP issuance planned). Contracts extended through: Annual SFY amendments — most recent effective 2024-07-01 (SFY25).

status=partial

## 1. How UT requires prior authorization Utah Medicaid requires prior authorization (PA) for a wide range of services and drugs. The PA structure is organized around four primary layers: - **InterQual-Licensed Medical Criteria**: Utah uses licensed InterQual criteria for many medical services, governed by go-live and version-effective dates (e.g., urinary-tract services tied to a 2023 InterQual version). - **Pharmacy PA PDFs**: Per-drug / per-drug-class criteria documents specifying patient eligibility, clinical documentation, and reauthorization rules. Examples in the sample: Movantik/Symproic, HAE prophylaxis (Cinryze, Danazol, Haegarda, Orladeyo, Takhzyro), GLP-1 weight-loss agents, continuous glucose monitors, Rukobia (fostemsavir), and others. - **Provider Manuals**: General PA-process guidance (medical necessity, step therapy, documentation) without per-service criteria. - **Coverage Lookup (R414)**: Coverage-eligibility lookup that references InterQual and pharmacy criteria but does not itself host detailed PA criteria. ## 2. How UT publishes and reports prior authorization Utah publishes PA requirements through several channels: - **InterQual Transparency / Cloud Tool**: Provides access to licensed InterQual criteria with go-live/version-effective dates (referenced at elt.medicaid.utah.gov). - **Pharmacy PA PDFs**: Published on the Utah Department of Health and Human Services (DHHS) Medicaid website, per drug/drug-class. - **Provider Manuals**: General PA-process guidance on the same DHHS site. - **Coverage Lookup (R414)**: Coverage-eligibility tool integrating the above. Reporting is conducted through the MMIS and internal tools tracking PA requests, approvals, denials, and reauthorizations. ## 3. UT's CMS-0057-F and prior-authorization-reform compliance posture - **WISeR: Not applicable.** Utah is **not** a WISeR (CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model) state. The six WISeR states are AZ, NJ, OH, OK, TX, WA. The synthesis's "WISeR pilot status unspecified" line has been corrected to not-applicable. - **CMS-0057-F**: A federal interoperability/PA **rule** Utah must align with. Utah's use of licensed InterQual criteria and published pharmacy PA PDFs supports the rule's evidence-based / transparency aims; specific compliance milestones are not detailed in the sample. The state's centralized PA portal is described as "partial." ## 4. How UT runs its own program Utah operates a managed-care-plus-carve-out structure: - **Managed Care Organizations (MCOs)**: Contracts extended via annual State Fiscal Year amendments (most recent effective July 1, 2024 / SFY25 per the sample). Named MCOs include SelectHealth, Molina, Healthy U, and Health Choice. - **Behavioral Health Carve-Out**: BH services carved out to county/local authorities. - **LTSS Carve-Out**: Managed via FFS and 1915(c) waivers. - **Pharmacy**: Partially carved in, with the state retaining significant oversight via detailed PA criteria. - **1115 Waiver**: Utah Medicaid Reform 1115 Demonstration (formerly Primary Care Network Demonstration). (A named fiscal-agent transition — ACS-Inc → Conduent/Gainwell — appears in the synthesis but is template-injected and unverified for Utah.) ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **InterQual-Licensed Criteria**: Distinctive reliance on licensed InterQual for medical services, with version/go-live dating. - **Pharmacy PA PDFs**: Detailed per-drug/per-class criteria. - **BH + LTSS Carve-outs**: County-managed BH; FFS/1915(c) LTSS. - **Medical + Pharmacy coverage**: The stratified sample captures **both** the medical track (InterQual criteria, Coverage Lookup R414, provider manuals) and the pharmacy track (numerous per-drug PA PDFs) — both are well represented. ### What's Missing/Uncertain: - **Per-document CPT/HCPCS codes**: Often absent from pharmacy PDFs. - **Effective/Revised dates**: Some documents lack them. - **Centralized portal**: "Partial"; integration status unclear. - **Gold Card Law / Foster-care program**: Unspecified in the sample. Overall, Utah's prior-authorization system is well-structured around licensed InterQual medical criteria plus detailed pharmacy PA PDFs, covering both medical and pharmacy benefits. Utah is not a WISeR participant.