Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since January 1, 2020, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

Rule R414-511. Medicaid Accountable Care Organization Incentives to Appropriately Use Emergency Room Services.

As in effect on January 1, 2020

Table of Contents

R414-511-1. Introduction and Authority.

(1) This rule is established under the authority of Section 26-18-408.

(2) The purpose of this rule is to establish provisions governing Accountable Care Organization (ACO) accountable performance measures for the reduction of non-emergent use of emergency departments by Medicaid beneficiaries.

R414-511-2. Definitions.

(1) "Non-emergent medical condition" means a medical condition that does not meet the criteria of an emergency medical condition under 42 U.S.C. 1395dd (e) of the Emergency Medical Treatment and Active Labor Act.

(2) "Non-emergent medical care" means:

(a) Medical care provided in an emergency room for the treatment of a non-emergent medical condition.

(3) "Non-emergent medical care" does not mean:

(a) Medical services necessary to conduct a medical screening examination to determine if the Medicaid beneficiary has an emergent or non-emergent medical condition; and

(b) Medical care provided to a Medicaid beneficiary who, using a prudent layperson standard, reasonably believes he is experiencing an "emergency medical condition" as defined by 42 U.S.C. 1395dd(e) of the Emergency Medical Treatment and Active Labor Act.

(4) "Medicaid Beneficiary" means a person who enrolls in an ACO in accordance with the Department's "Choice of Health Care Delivery Program" (CHCDP) freedom-of-choice waiver under Section 1915(b) of the Social Security Act.

R414-511-3. Performance Measures.

(1) An ACO that contracts with the Department to provide services to Medicaid beneficiaries shall report the following information to the Department in accordance with the terms of its contract:

(a) Emergency room visits with low acuity CPT codes 99281or 99282;

(b) Actions the ACO takes to expand primary care and urgent care for Medicaid beneficiaries who are enrolled in the Accountable Care Plan;

(c) Actions the ACO takes to implement emergency room diversion plans that include:

(i) Weekday, evening and weekend access to primary care providers and community health centers for Medicaid beneficiaries and

(ii) Other innovations for expanding access to primary care.

(d) Other quality of care for Medicaid beneficiaries who are enrolled in an ACO as required by the Department.



Date of Enactment or Last Substantive Amendment

January 13, 2014

Notice of Continuation

September 14, 2018

Authorizing, Implemented, or Interpreted Law

26-1-5; 26-18-3; 26-18-408

Additional Information


For questions regarding the content or application of rules under Title R414, please contact the promulgating agency (Health, Health Care Financing, Coverage and Reimbursement Policy). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.