Waiver Consulting Group — Start any program. In any state.

Utah - Case Management Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

Effective January 27, 2025, the Utah Office of Substance Use and Mental Health (SUMH) issues a single, unified Behavioral Health Case Management Certificate required for all non-licensed staff providing Targeted Case Management (TCM) under Utah Medicaid. This certification replaces the previously separate Adult, Children’s, and Homeless Services credentials, standardizing the baseline qualifications for coordinating medical, behavioral, and social services across the state.

Independent agencies seeking to bill Medicaid for behavioral health TCM must secure a contract with a county Local Mental Health Authority (LMHA) or a Prepaid Mental Health Plan (PMHP), as Utah operates its behavioral health Medicaid services under a managed care carve-out system. Providers targeting specific medical populations, such as the HIV/AIDS TCM program or the New Choices Waiver, must apply directly through the Utah Department of Health and Human Services (DHHS) Division of Integrated Healthcare and meet distinct programmatic criteria.

1. Service Definition and Scope

In Utah, Case Management is defined as a set of planning, coordinating, and monitoring activities that assist Medicaid clients in accessing needed housing, employment, medical, nutritional, social, and educational services. The state primarily covers this under Targeted Case Management (TCM) for specific populations, including individuals with Serious Mental Illness (SMI) and individuals diagnosed with HIV/AIDS.

The service scope mandates that case managers utilize standardized assessments to identify client needs and develop a person-centered service plan. Activities include advocating for the client, linking them to community resources, coordinating care with primary physicians, and monitoring progress to ensure services remain appropriate and effective.

2. Regulatory and Oversight Agencies

The Utah Department of Health and Human Services (DHHS) is the primary umbrella agency overseeing Medicaid and human services. Within DHHS, the Division of Integrated Healthcare manages the Medicaid program, sets policy, and operates the Provider Reimbursement Information System for Medicaid (PRISM).

The Office of Substance Use and Mental Health (SUMH) is responsible for the certification, training, and oversight of individual case managers. SUMH enforces the administrative rules governing case management practice and maintains the registry of certified professionals.

3. Gatekeeping Prerequisites: Who Can Even Apply

Utah utilizes a managed care carve-out model for behavioral health services. To provide and bill for TCM for individuals with Serious Mental Illness (SMI), an agency must be contracted with the regional Local Mental Health Authority (LMHA) or the designated Prepaid Mental Health Plan (PMHP) for that county. Medicaid will not enroll or reimburse independent TCM providers for SMI services outside of this contracted network.

For waiver-specific case management, such as the New Choices Waiver, providers must respond to open enrollment periods or specific solicitations issued by DHHS. Agencies cannot simply enroll as a waiver case management provider at any time; they must be approved by the waiver operating agency first.

4. Licensure and Certification Requirements

Utah does not issue a facility-level "Case Management Agency" license. Instead, oversight is maintained through the individual certification of staff and the agency's Medicaid enrollment. Under Utah Administrative Rule R523-7, all non-licensed individuals providing case management must obtain the Behavioral Health Case Management Certificate from SUMH.

To earn this certificate, applicants must complete a SUMH-approved 40-hour supervised practicum, submit a supervisor signature page, and pass the state certification exam with a score of 70% or higher. Licensed professionals (e.g., LCSWs, RNs) may provide case management under their respective professional licenses without this specific certificate.

5. Medicaid Provider Enrollment

Agencies must enroll as a Utah Medicaid provider through the Provider Reimbursement Information System for Medicaid (PRISM). The enrollment process requires the submission of ownership disclosure forms, proof of business registration, and verification of any required PMHP contracts or waiver approvals.

During enrollment, providers must select the appropriate provider type and specialty codes corresponding to Targeted Case Management. All enrolling agencies must pay the federal Medicaid application fee unless they have already paid it to Medicare or another state's Medicaid program.

6. Staffing, Training and Background Checks

Non-licensed case managers must meet strict baseline qualifications before beginning the certification process. They must be at least 18 years old, hold a high school diploma or GED, and have either 400 hours of experience in human services (within the last 10 years) or a Bachelor's degree in a related field.

Once certified, case managers must maintain their credential through ongoing education. SUMH requires 30 training hours every three years, which must specifically include ethics and suicide prevention training. All staff must also pass a comprehensive background check through the Utah Department of Public Safety.

7. Documentation, Policies and Records

Utah Medicaid requires meticulous documentation for all billed TCM services. Providers must maintain a comprehensive service plan for each client that identifies specific needs, goals, and the community resources required. This plan must be updated regularly based on the client's progress.

For every encounter, the case manager must document the date of service, name of the recipient, name of the provider agency and specific staff member, units of service, place of service, and a brief description of the exact service provided. Records must be retained in accordance with state and federal laws and be readily available for DHHS or SUMH audits.

8. Billing, Rates and Claims

TCM services are billed to Utah Medicaid using standard CMS-1500 claim formats or their electronic equivalents (837P) through the PRISM system. Services are typically billed in 15-minute increments, requiring providers to aggregate time spent on allowable case management activities.

Specific procedure codes vary by the target population. For example, HIV/AIDS Specialized Targeted Case Management has historically utilized specific state-designated codes (e.g., Y5400) billed in 15-minute units. Prior authorization requirements depend on the specific PMHP contract or waiver guidelines.

9. Approval Sequence and Timeline

The pathway to becoming a billing provider begins with securing the necessary network contracts (LMHA/PMHP) or waiver designations. Without this structural gate cleared, Medicaid enrollment cannot proceed. Concurrently, the agency must ensure all non-licensed staff complete the 40-hour practicum and pass the SUMH certification exam.

Once staff are certified and network approvals are in hand, the agency submits its enrollment application through PRISM. The PRISM review process typically takes 30 to 90 days, depending on application completeness and whether a site visit is required.

10. Common Denials and Survey Findings

Applications for Medicaid enrollment are frequently delayed or denied because the agency attempts to enroll as an independent TCM provider without the mandatory LMHA or PMHP contract. Additionally, PRISM applications will be rejected if ownership disclosures are incomplete or if the application fee is not paid.

During audits, the most common survey findings relate to documentation and staff credentials. Auditors frequently cite agencies for billing 15-minute units without corresponding encounter notes that detail the specific case management activity, or for utilizing staff whose SUMH certification has lapsed due to missing the 30-hour CEU requirement.

11. Key Contacts and Resources

Providers should rely on the official Utah DHHS and SUMH portals for the most current manuals, training schedules, and enrollment forms. The SUMH website hosts the monthly case management training links and the certification exam portal.

For Medicaid billing and enrollment technical assistance, providers must utilize the PRISM portal and the DHHS Division of Integrated Healthcare provider support lines.

See all Utah services · Utah Medicaid consulting · book a consultation.