1. Program Definition and Services

Case Management Services (Support Coordination) in Utah provide essential planning, advocacy, resource allocation, and clinical oversight for waiver participants. Administered across 1915(c) HCBS waivers via the Division of Services for People with Disabilities (DSPD), this service acts as the central hub of care to protect client health and safety. Services include:

• Person-Centered Assessment & Design: Executing standardized functional needs assessments and leading interdisciplinary teams to write, monitor, and update the Person-Centered Support Plan (PCSP) and Individual Support Plan (ISP)
• System Resource Coordination: Interfacing with community medical, educational, and behavioral networks, allocating individualized waiver budgets, and monitoring rendering service vendors for safety and contract compliance

2. Regulations

Operating as a case management provider requires alignment with state operational definitions and federal anti-conflict mandates:

• Utah Administrative Code, Rule R539-1 (Eligibility, Definitions, and Person-Centered Frameworks)
• Utah Administrative Code, Rule R539-2 (Service Coordination and Provider Performance Criteria)
• Utah Medicaid Provider Manual for HCBS Waivers (Conflict-Free Case Management Standards)
• Federal HCBS Final Settings Rule and Overlap Rules (42 CFR 441.301(c)(1)(vi))

3. Licensing or Certification

Providers do not require an institutional health facility license to run a standalone support coordination agency. Instead, companies must satisfy strict organizational criteria to be placed on the official DSPD Approved Vendor List (AVL). Individuals employed by the agency to execute independent plan management must maintain active state case management credentials and clear fingerprint-based background tracking systems.

4. Responsible State Agency

Two distinct divisions within the state health department coordinate programmatic oversight: The Utah Department of Health and Human Services (DHHS), via the Division of Services for People with Disabilities (DSPD), manages the case manager certification pipeline, approves care plans, and monitors quality metrics. The Division of Integrated Healthcare (DIH) retains administrative command over underlying Medicaid system enrollment, electronic claims verification, and PRISM configurations.

5. Application Process

Launching your case management agency involves a sequential process connecting your corporate structure to state networks:

• Register your business legal entity with the Utah Division of Corporations
• Establish secure corporate online credentials by creating an authorized Utah ID profile
• Complete comprehensive fingerprint-based background check clearances for all staff via the state portal
• Log into the Medicaid web infrastructure to complete electronic healthcare provider enrollment inside the PRISM portal
• Submit specialized conflict-free disclosures directly through the DSPD procurement system to execute a vendor contract

6. Required Documentation

To secure licensing and Medicaid validation, providers must compile an administrative folder containing:

• Corporate formation records, active Federal EIN, and Type 2 NPI files
• Confirmed PRISM Medicaid approval files and signed, executed DSPD vendor contracts
• Conflict-Free Case Management Assurance Attestation (certifying no financial or corporate cross-ownership ties to any direct direct-care rendering service providers)
• Case Management Services Policy & Procedure Manual (covering person-centered planning tracks, automated emergency contact timelines, monthly monitoring log structures, critical incident tracking, and data protection/HIPAA compliance)
• Certified undergraduate transcripts, professional resumes, and background verification cards for all hired support coordinators
• Certificates of commercial general liability insurance, professional errors & omissions (malpractice) insurance, and state-compliant workers' compensation insurance

7. Timeline for Approval

The processing pipeline spanning PRISM portal activation, conflict-free verification reviews, and final execution of the electronic DSPD vendor contract typically takes 2 to 4 months.

8. Pre-Application Process

Form an LLC or Corporation with the Utah Division of Corporations, secure an EIN from the IRS, and obtain a corporate Type 2 National Provider Identifier (NPI) specifically configured under case management, support coordination, or social work clinic taxonomy classifications.

9. Pre-Application Training

Before receiving participant assignments or navigating individual budgets, the agency's primary management team and all hired support coordinators must complete the online DSPD MySupport Provider Orientation training sequences and clear state-mandated Person-Centered Thinking modules.

10. Additional Notes

• Utah strictly enforces federal Conflict-Free Case Management (CFCM) guidelines, an agency approved to provide case management services is completely barred from billing or delivering direct hands-on waiver services (such as residential support, companion care, or day treatment) to the exact same participant
• According to state credentialing parameters, individual Case Managers must possess a minimum of a Bachelor's degree in social work, psychology, nursing, or a closely related human services field, paired with verified experience supporting individuals with intellectual or developmental disabilities
• Case managers are legally bound to perform regular, documented contact with the participant, including mandatory monthly monitoring reviews and quarterly in-person face-to-face evaluations to ensure the physical environment matches the goals defined in the ISP
• In accordance with state funding rules, case management agencies are directly responsible for the accurate transference of authorized per-unit rates within care plans; any failure to track or accurately communicate authorized limits to rendering vendors can result in direct state provider financial clawbacks

Why Choose Waiver Consulting Group?

Starting or expanding your Medicaid waiver-funded agency can feel overwhelming, but it doesn't have to be. At Waiver Consulting Group, we simplify the process by guiding you through licensing, compliance, provider enrollment, policies & procedures, and regulatory approvals in any state.

With proven expertise, a structured process, and ongoing support, we take the guesswork out of launching your healthcare business. Whether you're a first-time entrepreneur or an established provider looking to expand, our team ensures you stay compliant, competitive, and fully operational.