Medical Billing Company in Utah | Mixed ACO and Fee-for-Service Model

Utah Medicaid runs primarily through Accountable Care Organizations, the state's largest managed care program, with roughly 83 percent of Medicaid enrollees covered through comprehensive managed care across health plans including Healthy U, Health Choice Utah, Molina Healthcare, and SelectHealth Community Care. Unlike states with a single Medicaid MCO model, Utah keeps significant fee-for-service exposure alongside its ACOs, meaning a meaningful share of services are carved out of managed care contracts entirely and billed directly to the state. Practices need to identify, for each patient and service, whether the claim runs through an ACO plan's contracted rate or the state's published fee-for-service schedule, since the two paths use different reimbursement logic and different prior authorization rules. As of January 1, 2026, Utah implemented a Hybrid Unified Preferred Drug List that aligns pharmacy formularies between fee-for-service Medicaid and the ACO plans for specific drug classes, reducing (but not eliminating) coverage confusion between the two systems. Utah does not publish a single downloadable fee schedule; providers must use the state's online Coverage and Reimbursement Lookup tool at medicaid.utah.gov to confirm allowed amounts by CPT or HCPCS code. Mediknocx's billing team checks both ACO contract terms and the state fee-for-service tool before submitting Utah Medicaid claims, rather than assuming one rate structure applies across the board.