Utah behavioral health billing

Utah behavioral health billing for community providers.

HRI bills Utah Medicaid behavioral health claims, mental health and substance use, from enrollment through appeals: the state's rules and each plan's rules read together, authorization tracked to the date, and every claim reported each Friday.

Updated September 2026

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What Utah billing runs on

County plans, integrated plans and fee-for-service, sorted by member and county
An Office of Licensing license, then Medicaid enrollment in PRISM, then plan contracts
Per diem and 15-minute units, and a new institutional claim format in January 2027
Every claim reported every Friday

How Utah Medicaid pays behavioral health

Utah Medicaid is run by the Utah Department of Health and Human Services (DHHS) through its Division of Integrated Healthcare. Its Behavioral Health Services provider manual, updated September 2026, sets the covered services, codes and units, and it sends you to the member's plan for prior authorization when the member is in one. A second manual, Section I: General Information, covers enrollment, claims and filing. Who pays a given behavioral health claim, though, is decided by the member's county and coverage group, not by the service.

Most members get behavioral health through a prepaid mental health plan, or PMHP. DHHS contracts with each county's local mental health and substance abuse authority, or an entity that authority designates, to cover inpatient and outpatient mental health services and outpatient substance use disorder (SUD) services for the members who live there. Members are enrolled in the PMHP for their county of residence and have to use it for those services. The main exception is Adult Expansion Medicaid members in Davis, Salt Lake, Utah, Washington and Weber counties. They are required to join a Utah Medicaid Integrated Care plan, or UMIC plan, that covers physical and behavioral health together, and the PMHP rules do not apply to them. Wasatch County has no PMHP: its members are on the fee-for-service network, and any qualified Medicaid provider can bill the state.

The four accountable care organizations, Health Choice Utah, Healthy U, Molina Healthcare and Select Health Community Care, cover most physical health services and not behavioral health. The same four names run the integrated plans.

DHHS's county chart, dated August 2026, names who runs the PMHP in each county:

Salt Lake County: Salt Lake County Division of Behavioral Health Services, with Optum
Utah County: Wasatch Behavioral Health
Davis County: Davis Behavioral Health
Weber and Morgan: Weber Human Services
Summit County: Healthy U Behavioral
Tooele County: Optum Tooele County
Box Elder, Cache and Rich: Bear River Behavioral Health Services
Beaver, Garfield, Iron, Kane and Washington: Southwest Behavioral Health Center
Carbon, Emery and Grand: Four Corners Community Behavioral Health
Daggett, Duchesne, Uintah and San Juan: Northeastern Counseling Center, with San Juan Counseling Center serving San Juan County enrollees
Juab, Millard, Piute, Sanpete, Sevier and Wayne: Central Utah Counseling Center
Wasatch County: No PMHP. Fee-for-service: any qualified Medicaid provider bills the state, including the Wasatch County Family Clinic

Members in state custody, meaning foster care, are in the PMHP only for inpatient hospital psychiatric care. They can get outpatient mental health and substance use disorder services from any qualified Medicaid provider, who bills the state.

The billing consequence is direct. If a member is enrolled in a managed care plan, the state pays a claim only for a carve-out service, so a claim for a service the plan covers has to go to the plan. One carve-out to know: psychiatric evaluations and psychological testing done for physical health purposes, or to diagnose an intellectual or developmental disability or an organic disorder, are paid by the state, and the UC modifier tells the system to route them there.

Before the first claim: license, enrollment, contracts

For a new program the usual order is a license from the state's Office of Licensing, then Medicaid enrollment in PRISM, the state's Provider Reimbursement Information System for Medicaid, then a contract with each plan that will pay for your members.

Office of Licensing: DHHS's Office of Licensing, part of the Division of Licensing and Background Checks, licenses human services programs by category under Utah Administrative Code chapter R501. The categories that matter here are outpatient treatment (R501-21), day treatment (R501-20), residential treatment (R501-19) and social detoxification (R501-11).
Outpatient and IOP: Rule R501-21, last changed January 26, 2026, defines outpatient treatment to include early intervention, outpatient and intensive outpatient services on the continuum of care from the American Society of Addiction Medicine (ASAM). An intensive outpatient program has to run between nine and 19 hours a week for adults, or at least six hours a week for youth.
Day treatment: Rule R501-20 licenses day treatment and says it may be considered partial hospitalization on the ASAM continuum.
Residential treatment: Rule R501-19 covers residential treatment. A program serving substance use disorder clients can admit only clients whose level of care falls within ASAM levels 3.1 through 3.5. It has to document local government approval for a new program service or more capacity, it cannot turn a client away only because the client is on medication assisted treatment, and it has to make sure the client continues that treatment.
How to apply: You apply through the Office of Licensing's online portal with your city business license, fire and health department inspections, insurance, an organizational chart and, for day treatment, residential treatment and social detoxification, a floor plan. A residential program also files a notice of intent with the city. No sooner than four working days after you apply, you pay the fees and create a UtahID login, and everyone with direct or incidental client contact is screened through the Direct Access Clearance System. A licensor then reviews your policies, inspects the site and issues the license when every criterion is met. The initial license fee is $990 for outpatient, day treatment, residential treatment and social detoxification on the schedule that runs through June 30, 2027.
Medicaid enrollment: Once licensed, you enroll in Utah Medicaid through PRISM. You create a Utah ID, apply in PRISM and upload the Medicaid Provider Agreement and the access agreements. The state's enrollment forms page also lists an addendum for licensed substance use disorder residential programs with 17 or more beds, which names the program's license type and the ASAM levels it attests it can provide. Claims go in electronically through UHIN, the Utah Healthcare Information Network, or by direct upload to the PRISM portal.
Substance use disorder programs are high risk: In 2026 Utah moved substance use disorder treatment facilities into its high risk screening category. For a high risk provider, DHHS requires disclosure of every owner with a 5 percent or greater interest, fingerprint-based criminal background checks for those owners, and the federal application fee, $750 for 2026, unless the provider can show it already paid the fee to Medicare or another state's Medicaid program. DHHS may also make unannounced site visits before or after enrollment. Existing substance use disorder providers are being notified in phases starting in September 2026, and each has 60 days from the date on its letter to complete the screening or face closure.
The moratorium: On June 22, 2026 DHHS announced that it had received federal approval for a temporary moratorium on enrolling new substance use disorder and mental health rehabilitation providers in Utah Medicaid. It runs for an initial six months while the state reviews existing providers, and it covers applications already in progress. DHHS's July bulletin says it applies to new fee-for-service enrollments, that providers already in the network continue normally, and that an exception process for new providers will be available case by case. Neither the announcement nor the bulletin says how to ask for an exception.
Revalidation and closure: Utah revalidates enrolled providers at intervals of no more than five years, depending on risk level. DHHS mails the notice to the pay-to address in PRISM. A provider that has not finished within 60 days of the date on the letter gets a temporary payment hold, and one that has not finished within 90 days is terminated and has to enroll again as a new provider. DHHS can also close a provider that has not billed Medicaid for a year without notifying it.
How long it takes: DHHS's enrollment pages publish no processing time for a new application. The state pays only for services rendered during an enrollment period, and it gives you your effective date in an approval letter. Its 2022 provider-training material says the effective date is the date the application is correctly and completely submitted, and that a backdate can be requested for extenuating circumstances.

Joining each plan

Enrollment puts you in the state's system. It does not put you in a plan's network: Utah's manual tells providers to contact each plan directly. The state's prepaid mental health plan contract, in its Salt Lake County form for state fiscal year 2025, the latest posted, says a plan may pay only providers enrolled with DHHS. It lets a plan sign a network agreement for up to 120 days while enrollment is pending, and the agreement ends if the state has not enrolled the provider by then. This is what each plan's own page said on September 29, 2026.

County PMHPs: Each PMHP contracts with its own network. For Salt Lake County the state's chart lists the county's Division of Behavioral Health Services with Optum, and Optum's Salt Lake County page for network providers links to a network application. For the other counties, use the plan named on the county chart above.
Healthy U: University of Utah Health Plans decides applications on its business needs, including network adequacy, the needs of each geographic area and provider specialty. You submit the provider application, its contracting committee reviews it within 45 to 60 business days, and credentialing typically takes 6 to 8 weeks once the signed agreement is in. The plan says it is not currently accepting applications from mid-level, non-prescribing behavioral health providers in Salt Lake, Utah, Davis, Weber and Washington counties. Healthy U Behavioral is the PMHP for Summit County.
Health Choice Utah: Complete its Provider Application Form. Its page says it is no longer accepting applications from non-prescribing mid-level behavioral health solo practitioners in Salt Lake, Utah, Davis, Weber and Washington counties.
Molina Healthcare of Utah: To join, you must first be enrolled with DHHS and apply for or hold an active Medicaid ID. Then you complete a contract request form and send it with a current W-9 to Molina's Utah contracting address.
Select Health Community Care: Select Health's Utah join page has a clinician path that uses CAQH for credentialing, and a facility path described for hospitals, skilled nursing, long term care and rehabilitation facilities. It does not name behavioral health agencies, so confirm the path with Select Health.

Where a plan's page gives a review time, that is the plan's figure, not the state's. None of these pages promises a date for a new agency, so plan on each contract running on its own clock.

The codes and units on a Utah claim

Utah's codes and units come from the state's Behavioral Health Services manual. These are the main codes for the programs this page covers. Rates change, so this page leaves them out. When the member is in a plan, the plan's rules apply too, so confirm them before you submit.

90791, 90792, 90846, 90847, 90849, 90853: Evaluations and family, multiple-family and group psychotherapy are billed in 15-minute units today. Under the manual's time rules, less than 8 minutes is zero units, 8 to 22 minutes is one unit, 23 to 37 minutes is two, and so on. Group psychotherapy is limited to 12 members, or 16 with a co-provider, and a group over the limit cannot be reported for any member in it. In January 2027 these codes move to one unit per day.
H2019, H2019 with HQ: Therapeutic behavioral services, individual or family, or group with the HQ modifier, in 15-minute units. A group is limited to 12 members, or 24 with a co-provider.
H2014, H2017, H2017 with U1: Psychosocial rehabilitative services in 15-minute units: H2014 is individual, H2017 is group and H2017 with U1 is an intensive group. A group is limited to 12 members per provider and 36 in all. An intensive group is limited to five members per provider and 10 in all, and the record has to show why the member needs it. For groups run in a licensed day treatment or residential program, each date needs the group name, start and stop time and setting, plus a summary note for each type of group every two weeks.
H0038, H0038 with HQ: Peer support in 15-minute units. The specialist has to be certified through the Office of Substance Use and Mental Health, a licensed mental health therapist has to refer the member, and a group with a ratio above 1 to 8 cannot be reported for anyone in it.
H0012, H0014: Withdrawal management, both per diems. H0012 is social detox from a program licensed by the Office of Licensing as a social detoxification facility that meets ASAM criteria. H0014 is medically managed outpatient treatment. A per diem can be reported only for a date on which at least one included service is provided.
H2036, H0018: Substance use disorder residential treatment, per diem, one code for each size of program. H2036 is for programs of 16 or fewer beds and H0018 for programs of 17 or more, which are institutions for mental diseases (IMDs). Prior authorization is required for every member, and the manual limits the service to members 12 and older.
H2013, H0017: Mental health residential treatment, per diem. H2013 is for members 21 and older in a program of 16 or fewer beds; for members under 21 in such a program, providers report the individual services. H0017 is for programs of 17 or more beds and only for members 21 through 64, with prior authorization and a limit of 60 days per episode. If a stay runs past 60 days, none of the days in that episode are payable.
IOP and PHP: The manual has no IOP or PHP chapter and no per diem code for either. DHHS first announced a new method for these programs for July 1, 2026 and has moved it to January 1, 2027. From that date IOP, PHP and residential claims go on the institutional 837I, one unit per day, with a revenue code and a HCPCS code. IOP for psychiatric care is 0905 with S9480, and IOP for chemical dependency is 0906 with H0015. PHP less intensive is 0912 with H0035, and PHP intensive is 0913 with H0037. Residential is 1001 with H0017 or H2013 for mental health, and 1002 with H0018 or H2036 for substance use. The bulletins speak of claims to Medicaid, so ask each plan how it will take these for its own members.

Bundled days, documentation and unlicensed staff

Per diem codes are bundles. The manual's bundled code table lists the services that sit inside each one, and the same provider cannot bill them separately on the same date. In the residential bundles they include evaluations, psychotherapy, peer support, psychosocial rehabilitation, therapeutic behavioral services and case management. Supportive living, H2016, cannot be reported on a day the residential per diem is reported. A per diem can be reported only for a date on which the member received at least one behavioral health service.

Every service needs a record of what was done: the service, the date with start and stop time and duration, the setting (with a note when it was telehealth), a summary of the goal addressed, the intervention and what happened, and the signature and credentials of the person who did it. A mental health therapist writes the treatment plan and reviews it as clinically indicated. When a service is bundled, each service inside the bundle still needs its own documentation.

Since December 1, 2025, unlicensed behavioral health staff, such as unlicensed staff providing psychosocial rehabilitation, students working toward licensure and people accruing hours toward a social service worker license, no longer enroll in PRISM. A licensed supervisor reports their services under the supervisor's NPI with the HL modifier, checks the federal exclusion list and the System for Award Management every month, and keeps a record of the checks.

Medicaid is the payer of last resort, so other insurance is billed first. A provider who accepts a member accepts Medicaid's payment in full, with narrow exceptions, and cannot bill the member for the difference. Claims to the state have to be received within 365 days of the date of service. For an institutional claim that spans dates, the count starts from the end date, and adjustments have to arrive inside the same 365 days. Each plan's window comes from its own provider agreement, so read each one.

Prior authorization for residential care

For a member on fee-for-service, the state's manual sets the rules for substance use disorder residential treatment and for mental health residential treatment in an IMD, and requests go in through PRISM. A member in a plan follows the plan's own authorization rules, and the manual sends you to the plan. Molina's manual, for one, lists substance use disorder residential services among those it handles through its prior authorization process.

SUD residential, first request. Submit it within two business days of admission. It needs no clinical documentation, and there is one initial request per treatment episode. Adults can be approved for up to 60 calendar days per request, and adolescents 12 through 18 for up to 30.
SUD residential, continued stay. The request is due no later than the first requested date of service and must include a completed ASAM reassessment and treatment plan review, and it can be submitted only within the four calendar days that end on that date. If the provider finds continued stay is not medically necessary, it can ask for up to 14 transition days.
Mental health residential in an IMD. The service is covered only for members 21 through 64, and prior authorization is required. Each request covers up to seven calendar days, the first needs no documentation and is due within two business days of admission, and no more than 60 days in all can be authorized per episode, whatever the medical necessity.
Absences and changes. An absence of three calendar days or less needs a modification request form. A longer absence needs a new non-clinical authorization. A modification request that arrives more than 10 calendar days after the modification date is untimely and denied.
A member who changes plans mid-stay. In SUD residential, if a plan authorized the first days and the member moves to fee-for-service, continued stay requests must be submitted in PRISM. In mental health residential in an IMD, a change in coverage either way means the later requests have to be clinical requests.

What changes on January 1, 2027

Several state changes land on the same date, and each one touches how a claim is built or whether the member is covered.

IOP, PHP and residential move to the 837I. One unit per day, with a revenue code and a HCPCS code on each claim. The pairs are in the codes section above.
Evaluations and family and group psychotherapy leave 15-minute units. The September bulletin puts 90791, 90792, 90846, 90847, 90849 and 90853 on one unit per day, with a minimum time for each. Read the bulletin's table before you bill group or family sessions.
Telehealth claims need modifier 93 or 95. Modifier 93 is for audio-only service and 95 for audio and video. DHHS had set October 1, 2026 and moved the date to January 1, 2027.
New rates. DHHS rebased its behavioral health code rates. New rates took effect July 1, 2026, and another set starts January 1, 2027.
Eligibility rules for Adult Expansion. Adults 19 through 64 in Adult Expansion and Targeted Adult Medicaid have to show 80 hours a month of community engagement unless they are excluded, and people taking part in a drug or alcohol treatment and rehabilitation program are among those excluded. Adult Expansion and Targeted Adult members also move to six-month eligibility reviews. Separately, Medicaid eligibility for some immigrant groups narrows on October 1, 2026. Check eligibility and plan on the date of service, not at admission.

Where Utah claims break

In every case below the care was delivered and the claim still failed.

The wrong payer. A claim goes to the state for a service the member's plan covers, or to the wrong county's plan, and it denies. An Adult Expansion member in Salt Lake County is on an integrated plan, not the county PMHP.
Enrollment that is not active. Utah pays only for services in an enrollment period, and plans may pay only enrolled providers. A revalidation notice missed at the pay-to address turns into a payment hold at 60 days and termination at 90.
A residential authorization deadline missed. The first request is due within two business days of admission, the continued stay request needs the ASAM reassessment in time, and a modification filed after 10 days is denied.
A per diem billed for a day with no service, or on top of one. A per diem needs at least one behavioral health service that day, and the services bundled into it cannot be billed separately by the same provider on the same date.
A group over the cap, or a service under 8 minutes. A group over its member limit cannot be reported for any member in it, and a service under 8 minutes is zero units.
Unlicensed staff billed under their own NPI. Their services go under the licensed supervisor's NPI with the HL modifier, and the supervisor's monthly exclusion checks have to be on file.
The wrong residential code for the bed count. Sixteen or fewer beds and 17 or more bill on different codes, and mental health residential care in an IMD stops paying if the episode passes 60 days.
Other insurance not billed first, or a late claim. Other coverage is billed before Medicaid. The state has to receive a claim within 365 days of the date of service, and each plan's window is in its own agreement.
A claim format that changes in January. IOP, PHP and residential claims have to be built for the 837I with revenue code and HCPCS pairs from January 1, 2027.

What we do about it

HRI is based in Salt Lake City and runs Utah behavioral health billing under HRI Managed. That means benefit verification that starts with the member's county and coverage group, authorization and concurrent review tracked to the date, and claims built to the state manual and each plan's rules before they go out. In Utah it also means putting each residential authorization deadline on the calendar the day a member is admitted, and building IOP, PHP and residential claims for the January 2027 institutional format. A denied or stuck claim runs through the same seven-point diagnostic we apply to every claim. Every claim is reported to you every Friday, with its status, its age and the next action.

Opening a Utah program

The license decides when you can enroll, so start there. If your program is a substance use disorder or mental health rehabilitation program, plan around the moratorium: DHHS says an exception process will be available case by case and has not said how to ask for one. We prepare the PRISM screens and the plan contract requests and track each one to a decision. Your organization signs the Medicaid provider agreement.

We do not bill for a date of service before the effective date the state and the plan have confirmed. One rule is fixed: no claim goes to a payer until that payer confirms enrollment and an effective date. The order of work, what to have ready and the first 90 days are on the new-program billing page.

What it costs

Utah billing is priced the same way as the rest of our billing, by who pays the claim. Any claim Utah Medicaid pays, in whole or in part, through DHHS, a county prepaid mental health plan or an integrated plan, carries a flat fee per claim, set per program day or per encounter where that fits, with a monthly minimum. The Medicaid fee is never a percentage of what is billed or collected, and it is owed whether or not the claim pays. Commercial insurance and Medicare claims carry a monthly minimum or a percentage of what payers pay, whichever is greater, never both. Every rate is fixed in writing before the first claim. Payers pay you directly, and we never receive payer money. Ending the agreement early outside its own exit terms carries an early-exit fee, set in the agreement. There is no setup fee when your operation is ready as it stands. Credentialing and enrollment work is priced separately, per service, in writing.

On Utah Medicaid claims, your fee follows the claims we file, not what payers pay. Your exact numbers are set on a written quote after a billing review.

What HRI will not do

We will not promise a plan's authorization decision, a reimbursement rate, an enrollment or licensing date, or an exception to the enrollment moratorium. Those calls belong to the plan, DHHS and the Office of Licensing. We will not bill a Utah claim before enrollment and an effective date are confirmed. And we have no say in what level of care a patient gets: that decision belongs to your clinical team.

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Utah billing, answered

What Utah providers ask about billing.

What do we need before Utah Medicaid will pay a new behavioral health program?

Three things, usually in this order. First, a license from the Office of Licensing for the kind of program you run: outpatient treatment, day treatment, residential treatment or social detoxification. Second, Utah Medicaid enrollment through PRISM. Third, a contract with each plan that pays for your members, which is the county's prepaid mental health plan, or an integrated plan for Adult Expansion members in five counties. Enrollment does not put you in a plan's network, and a prepaid mental health plan may pay only providers who are enrolled with DHHS. For substance use disorder and mental health rehabilitation programs, DHHS announced a temporary moratorium on new enrollments in June 2026.

Is Utah Medicaid enrolling new substance use disorder programs right now?

As of September 2026, new enrollments are paused. On June 22, 2026 DHHS announced a temporary moratorium, approved by CMS, on new substance use disorder and mental health rehabilitation provider enrollments, for an initial six months, including applications already in progress. DHHS's July bulletin says it applies to new fee-for-service enrollments and that a case-by-case exception process will be available, and neither document says how to ask for one. DHHS does not expect the pause to affect its managed care plans or local mental health authorities. Substance use disorder facilities are also in the high risk screening category now: owners with a 5 percent or greater interest are fingerprinted, DHHS can make unannounced site visits, and the $750 federal fee applies.

Who pays a Utah behavioral health claim: the county, an integrated plan or Medicaid?

It depends on the member's county and coverage group. Most members are in the prepaid mental health plan for their county, which covers inpatient and outpatient mental health services and outpatient substance use disorder services. Adult Expansion members in Davis, Salt Lake, Utah, Washington and Weber counties are required to join an integrated plan instead, one that covers physical and behavioral health together. Wasatch County has no prepaid mental health plan, so the state pays behavioral health claims there directly. If a member is enrolled in a plan, the state pays only carve-out services, so a claim for a plan service sent to the state is denied. Confirm each member's plan on the date of service.

How are IOP and PHP billed to Utah Medicaid?

The state's behavioral health manual has no IOP or PHP chapter and no per diem code for either, so until January 1, 2027 the codes the manual offers are the component services, such as group psychotherapy (90853) and group psychosocial rehabilitative services (H2017), in 15-minute units. On January 1, 2027, IOP and PHP claims move to the institutional 837I format, one unit per day: IOP for psychiatric care is revenue code 0905 with S9480, IOP for chemical dependency is 0906 with H0015, PHP less intensive is 0912 with H0035 and PHP intensive is 0913 with H0037. Licensing rule R501-21 says an adult IOP runs nine to 19 hours a week and a youth IOP at least six. DHHS's bulletins speak of claims to Medicaid, so ask each plan how it will take them.

What does Utah require for residential authorization?

For members on fee-for-service, substance use disorder residential treatment needs prior authorization for every member. The first request is due within two business days of admission and needs no clinical documentation. Adults can be approved for up to 60 days per request and adolescents 12 through 18 for up to 30. A continued stay request needs a completed ASAM reassessment and treatment plan review, and an absence of more than three calendar days needs a new authorization. Mental health residential treatment in a program with 17 or more beds is limited to members 21 through 64 and to 60 days per episode, and past 60 days none of the days in the episode are payable. A member in a plan follows that plan's authorization rules.

How long does Utah Medicaid enrollment take?

DHHS's enrollment pages publish no processing time for a new application, and the state pays only for services rendered during an enrollment period. The times that are published belong to other steps. University of Utah Health Plans says its contracting committee reviews applications within 45 to 60 business days and that credentialing typically takes 6 to 8 weeks after the agreement is signed. A prepaid mental health plan may sign a network agreement for up to 120 days while state enrollment is pending. For substance use disorder and mental health rehabilitation programs, the moratorium comes first.

Do you charge a percentage?

Not on Medicaid claims. Any claim Utah Medicaid pays, in whole or in part, through DHHS, a county prepaid mental health plan or an integrated plan, carries a flat fee per claim, set per program day or per encounter where that fits, with a monthly minimum, never a percentage of what is billed or collected, and owed whether or not the claim pays. On commercial insurance and Medicare claims, we charge a monthly minimum or a percentage of what payers pay, whichever is greater, never both. Every rate is fixed in writing before the first claim goes out, and payers pay you directly.

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Last updated: September 30, 2026