CurrentColorado Rocky Mountain Health PlansPolicy 2025R8003B

Influenza testing reimbursement on CMS-1500/UB04

Defines UnitedHealthcare Commercial and Individual Exchange reimbursement methodology for influenza diagnostic testing billed on CMS-1500 or UB04 forms and the specific clinical conditions for which testing will be considered; applies to all network and non-network providers under UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyInfluenza testing reimbursement on CMS-1500/UB04

Policy CodePolicy 2025R8003B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims using CMS-1500 or UB04 (or electronic equivalent) with the codes that correctly describe the services provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6listed reimbursable diagnostic procedure codes (primary set)

22listed clinical conditions that permit reimbursement

2testing types explicitly not reimbursed (viral culture, serology)

CMS-1500, UB04claim forms covered by policy

Influenza Testing Coverage Criteria

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Influenza testing coverage criteria

Reimbursement is considered only when the service is billed with one of the specified clinical conditions listed below; specific test types are excluded from reimbursement.

Covered when ALL of the following are met:

ALL of the following

Procedure code billed is one of the reimbursable influenza diagnostic test codes (see coding section for specific CPT mappings).see coding list
Procedure codes referenced in policy are for reference; UnitedHealthcare may apply discretion.
Claim is billed with one of the enumerated clinical conditions listed below (condition linkage required).

One of the following clinical conditions must be present

Abdominal Pain
Acute bronchitis
Acute sinusitis
Acute tonsillitis, laryngitis and tracheitis
Asthma exacerbation
Chest pain
Cough
Dehydration
Fatigue
Fever
Gastritis, unspecified, without bleeding
Headache
Infectious mononucleosis
Influenza
Nausea, vomiting
Pharyngitis
Shortness of breath
Upper respiratory infection
Viral infections
Viral intestinal infection, unspecified
Viral or bacterial pneumonia
Whooping cough

Exclusions (not reimbursed)

Viral culture testing for influenza (CPT 87254) is not reimbursed.
Serology testing for influenza (CPT 86710) is not reimbursed.

Reimbursable and Non-Reimbursable Codes

Reimbursable influenza diagnostic test codesCPTCovered

87275	87275
87276	87276
87400	87400
87501	87501
87502	87502
87804	87804

Non-reimbursable influenza test codesCPTNot Covered

87254	87254 - Viral culture testing for influenza
86710	86710 - Serology testing for influenza

Clinical condition linkage required

Reimbursement conditionReimbursement will be considered only when the influenza testing procedure code is billed with one of the specified clinical conditions listed in this policy (see enumerated condition list)

Applicable conditions (examples)Includes fever, cough, upper respiratory infection, influenza, chest pain, shortness of breath, viral infections, pneumonia, asthma exacerbation, pharyngitis, dehydration, headache, abdominal pain and others as enumerated

LimitationUnitedHealthcare will not consider reimbursement of the listed influenza testing procedure codes for any conditions other than those enumerated in the policy

Claims Submission and Billing Responsibilities

Documentation Required

Claims submission and coding responsibility

You are responsible for submission of accurate claims using the CMS-1500 or UB04 (or electronic equivalent). Reimbursement will be based on the code or codes that correctly describe the health care services provided; use CPT/CMS coding guidelines for definitions but note they do not guarantee reimbursement.

Submit claims on the CMS-1500 or UB04 form (or electronic equivalent).
Report the code or codes that accurately describe the services rendered; coding guidelines may be used for reference.
Understand that references to CPT/CMS are definitional and do not by themselves establish a right to reimbursement.

Scope and Coding Definitions

Accurate coding

RequirementClaims must be submitted with the code or codes that correctly describe the health care services provided; reimbursement is based on submitted codes

Coding guidanceProviders may use CPT, CMS or other coding guidelines for definitions, but references do not guarantee reimbursement

ResponsibilityYou are responsible for submission of accurate claims; coding methodology and other factors are considered when developing reimbursement policy

Scope / Application — forms and reporting

Accepted claim formsCMS-1500 (1500 Health Insurance Claim Form), UB04, or electronic equivalent

Scope of applicationApplies to all products, all network and non-network physicians and other qualified health care professionals, outpatient facility claims, ASCs, OSCs

Electronic submissionPolicy applies to electronic equivalent or successor claim forms as specified