CurrentColorado Rocky Mountain Health PlansPolicy 2025R8200A

Hemoglobin A1C testing reimbursement frequency and coding guidance

Defines UnitedHealthcare Medicare Advantage reimbursement methodology and frequency limitation for hemoglobin A1C testing billed on UB04 or CMS 1500 forms for Medicare Advantage enrollees.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHemoglobin A1C testing reimbursement frequency and coding guidance

Policy CodePolicy 2025R8200A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionBill hemoglobin A1C procedure codes no more than once per 90 consecutive calendar days per member; either code counts toward the shared frequency limit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

once every 3 monthsallowed reimbursement frequency for A1C testing for listed conditions

2 codesProcedure codes referenced

Type 1/Type 2Conditions subject to the frequency limitation

MA productspolicy applicability

Hemoglobin A1C Reimbursement Criteria

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Hemoglobin A1C reimbursement criteria

UnitedHealthcare will consider reimbursement of hemoglobin A1C procedure codes subject to frequency limitations for specified conditions.

Reimbursement is for procedure code 83036 or 83037 billed.

Member has a diagnosis of Type 1 or Type 2 diabetes mellitus.

Frequency limitation: testing reimbursed no more than once per 90 consecutive calendar days per member (‘‘once every three months’’).

Once every three months = 90 consecutive calendar days from the initial date of service.

The once-every-90-days limitation applies regardless of billing or rendering provider (any individual provider or any facility).

Billing either procedure code counts toward the shared frequency limit (both codes count together).

Exceptions/Other billing scenarios

If the hemoglobin A1C codes are billed for conditions other than Type 1 or Type 2 diabetes mellitus, the frequency limitation in this policy does not apply.

Procedure Codes and Frequency

Hemoglobin A1C testingCPTCovered

83036	Hemoglobin; glycosylated (A1C) - single test
83037	Hemoglobin; glycosylated (A1C) - second code variant

Frequency limit

Frequency limit1 per 90 consecutive calendar days per member for hemoglobin A1C testing when billed for Type 1 or Type 2 diabetes mellitus

Applies across providers and facilitiesLimit is applicable regardless of billing and/or rendering provider (any individual provider OR any facility) for the same member

Shared limit for procedure codesBilling either procedure code (83036 or 83037) counts toward the same frequency limit

Counting period definitionOnce every three months = 90 consecutive calendar days from the initial date of service

Billing and Reimbursement Limitations

Billing Rule

A1C frequency limitation — 1 per 90 days for Type 1 or Type 2 diabetes

UnitedHealthcare will consider reimbursement of hemoglobin A1C procedure codes once every three months (90 consecutive calendar days) for members when billed for Type 1 or Type 2 diabetes mellitus. Billing either procedure code (83036 or 83037) counts toward the shared frequency limit regardless of billing or rendering provider or facility.

Limit applies per member regardless of individual provider or facility.
Frequency defined as 90 consecutive calendar days from the initial date of service.
Both procedure codes (83036 and 83037) count toward the same frequency limit.

Scope and Timing Definitions

Policy application

Plan applicabilityApplies to all UnitedHealthcare Medicare Advantage products

Claims formsApplies to network provider services reported using UB04 (CMS 1450) and CMS 1500 forms or their electronic equivalents

Scope notePolicy governs reimbursement methodology and coding for services billed on UB04 and CMS 1500 forms

Once every three months

Definition (once every three months)Once every three months = 90 consecutive calendar days from the initial date of service

Frequency interpretationThe 90‑day period is measured from the initial date of service for the A1C test

Provider-agnostic limitThe 90‑day limitation applies regardless of which provider or facility bills the service for the member