CurrentColorado Rocky Mountain Health PlansPolicy 2025R9067A

Reimbursement for home health services billed on CMS 1500 and UB04

This policy governs reimbursement rules for UnitedHealthcare Medicare Advantage for services billed on UB04 (CMS 1450) and CMS 1500 forms, specifically addressing when home health services (POS 12 or specified UB-04 bill types) are reimbursed in relation to inpatient care; it affects network and non-network providers submitting claims for Medicare Advantage members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for home health services billed on CMS 1500 and UB04

Policy CodePolicy 2025R9067A

Change TypeNo material change

Effective Date

Next Review DateJul 1, 2025

Key ActionSubmit accurate claims using the correct codes per CPT/CMS guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

POS 12/UB-04Forms/indicators required to identify home health services

Inpatient onlyWhen both inpatient care and home health billed same dates

May reimburseAdmission/discharge exception

All MA productsScope

DME

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Home Health Reimbursement During Inpatient Care

Home health during inpatient stay

Covered when the following reimbursement rules are met:

Home health services are submitted with Place of Service (POS) 12 on a CMS-1500 claim form or with UB-04 bill type 321-329, 341-345, or 347-349 (indicates services provided in a private residence).

If home health services and inpatient care are billed for the same dates of service, UnitedHealthcare will reimburse inpatient care only; home health services for those overlapping dates are not eligible for reimbursement.

Exceptions

Home health services provided on the inpatient admission date may be eligible for reimbursement.
Home health services provided on the inpatient discharge date may be eligible for reimbursement.

Home health services may include part‑time or intermittent skilled nursing, physical therapy, occupational therapy, speech‑language pathology, home health aide services, medical social services, durable medical equipment (DME), and medical supplies. DME and POS definitions are governed by CMS guidance.

Operational note

Service Identifiers and Overlap Rules

Home health service identifiersmixedCovered

POS 12	Place of Service code indicating services provided in a private residence (home health)
UB04 type of bill 321-329, 341-345, 347-349	UB-04 bill types indicating home health services

Overlapping inpatient/home health dates

RuleWhen home health services (POS 12 on CMS-1500 or UB-04 bill types 321-329, 341-345, or 347-349) and inpatient care are billed for the same dates of service, UnitedHealthcare will reimburse the inpatient care only; home health services for those overlapping dates are not eligible for reimbursement.

Admission/Discharge ExceptionHome health services provided on the dates of inpatient admission or discharge may still be eligible for reimbursement.

Required claim indicatorsHome health services must be submitted with POS 12 on a CMS-1500 or with UB-04 bill types 321-329, 341-345, or 347-349 to be identified as home health.

Claims Submission and Policy Monitoring

Billing Rule

Claims submission responsibility

You are responsible for submitting accurate claims using the correct forms, codes, and coding guidelines. This policy uses Current Procedural Terminology (CPT®), Centers for Medicare & Medicaid Services (CMS), and other standard coding guidance to determine appropriate reimbursement. Submit claims on the appropriate UB-04 (CMS 1450) or CMS 1500 forms and ensure codes accurately describe the services rendered. UnitedHealthcare Medicare Advantage reimbursement policies are intended to guide coding and reimbursement but do not guarantee payment; other factors (legislative mandates, provider contracts, member benefit design, and other policies) may affect reimbursement.

Use appropriate CPT, CMS, or other recognized coding guidelines
Bill on UB-04 (CMS 1450) or CMS 1500 as applicable
Ensure codes selected accurately describe services provided
Accurate claim submission is the provider's responsibility

Note

Key Terms

Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME): Medical equipment which can withstand repeated use, is not disposable, is used to serve a medical purpose, is generally not useful in the absence of sickness or injury, and is appropriate for use in the home.

CharacteristicsCan withstand repeated use; not disposable; used to serve a medical purpose; generally not useful without sickness or injury; appropriate for home use.

ContextDME may be included as part of home health services when billed with the appropriate POS or UB-04 bill types.

Place of Service

DefinitionPlace of Service: A two-digit code used on health care professional claims to indicate the setting in which a service was provided.

Home health indicator