Medicaid Online

There are four information systems available for providers to verify member eligibility and claim status for Utah Medicaid services:

• PRISM (https://prism.health.utah.gov/) - A portal that provides member eligibility, coverage information and claim status to providers.
• HIPAA 270 and HIPAA 276 – an indirect connection to the Medicaid computer system to request member eligibility and claim status.
• Eligibility Lookup Tool ( https://elt.medicaid.utah.gov/ ) - a website to electronically view a member’s Medicaid eligibility.
• Coverage and Lookup Tool (http://health.utah.gov/stplan/lookup/CoverageLookup.php ) - a website to electronically view healthcare code coverage information based on provider type and member benefit plan.

PRISM

The PRISM portal allows providers to look up member eligibility and claim status by using the EXT Member Provider Access or Claims Inquiry profile roles respectively. For help adding roles to a provider username, review instructions and other helpful information here: https://medicaid.utah.gov/Documents/pdfs/ProviderAccountAdminManual.pdf .

HIPAA 270 and HIPAA 276

These two HIPAA compliant transactions provide member eligibility and claim status for providers who are enrolled with Utah Medicaid. To use these tools:

• Obtain a Trading Partner Number (TPN), from your Clearinghouse, Billing Agent or Utah Health information Network (UHIN ) at (877) 693-3071.
• Use any 5010 HIPAA compliant practice management system that permits 270 and/or 276 HIPAA batch transaction exchanges to retrieve Utah Medicaid responses within twenty-four hours from submission.
• Use any 270 or 276 CAQH Core compliant management software system to send and receive Real Time eligibility and claim status requests within twenty seconds.

For instructions and more specific information about the HIPAA 270 and HIPAA 276 file requirements, check out the following links:

Eligibility Lookup Tool

The Eligibility Lookup Tool – (https://elt.medicaid.utah.gov/) is a website that allows a provider to electronically view a member’s Medicaid eligibility and plan enrollment information. The Eligibility Lookup Tool will also tell you if the member is restricted to a specific provider and if the member is responsible for co-pays. In addition, the Eligibility Lookup Tool can be used to verify Utah Medicaid and Children’s Health Insurance Program (CHIP) eligibility. Training materials on how to use the Eligibility Lookup Tool are available: https://medicaid.utah.gov/elt-training/.

Providers can look up Prior Authorization status through the PRISM portal by using the EXT PA Provider Access profile. For information how to perform a PA inquiry review the instructions found here: Facilitator and User Guides to review the PA Inquiry steps. There are several Prior Authorization step by step guides, please choose the one that fits your medical area of specialty. For other frequently asked questions check out the Provider FAQ for Prior Authorizations: https://medicaid.utah.gov/Documents/pdfs/PROVIDER%20FAQ_Prior-Authorization.pdf

Coverage and Lookup Tool

The information provided by the Coverage and Lookup Tool ( http://health.utah.gov/stplan/lookup/CoverageLookup.php ) does not guarantee payment. It is intended to provide coverage and payment information for selected procedure codes as of the "Updated On" date specified in the search results. For additional information regarding specific billing requirements, coverage or rates not managed in this Lookup tool, please consult the Medicaid Provider Manuals.

Helpful Links: