CurrentColorado Rocky Mountain Health PlansPolicy N/A

Procedure and Place of Service (POS) reimbursement

Defines UnitedHealthcare Community Plan's reimbursement rules for CPT/HCPCS codes based on appropriate Place of Service (POS) reporting for Medicaid products; affects physicians and other qualified health care professionals submitting CMS-1500/UB04 claims.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProcedure and Place of Service (POS) reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims with CPT/HCPCS codes reported with an appropriate Place of Service (POS).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500 / UB04claim form applicability

CMS POS setPOS code standard

maintainedcode-to-POS list

not all codescoverage gaps

multiplestate exceptions

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POS-based reimbursement criteria

Reimbursement is allowed when ALL of the following are met:

Codes must be reported with an appropriate Place of Service (POS). UnitedHealthcare aligns with the CMS POS code set (two-digit POS codes submitted on the CMS 1500).

If a CPT/HCPCS code's description or coding guidelines specify allowable place(s) of service, the code must be billed only in those POS (UnitedHealthcare maintains a list of CPT/HCPCS codes with their appropriate POS).

Codes assigned the CMS Non-Facility Indicator 'NA' will not be considered for reimbursement when reported without an appropriate POS.

Codes assigned the CMS Facility NA Indicator 'NA' will not be reimbursed on professional claims billed with facility POS 21.

Procedures billed with an appropriate POS remain subject to other UnitedHealthcare Community Plan reimbursement policies.

Place of Service coverage rules

Coverage is expressed as allowed or denied billing of specific CPT/HCPCS codes in defined POS (state-level exceptions and allowances apply):

State-specific rules

Texas Medicaid: lists codes explicitly allowed in specific POS and other codes denied in many POS (see Texas details).
Washington: per state guidelines, specific codes are exempt or payable in listed POS (examples include CPT 99202-99215 allowed in certain POS; behavioral health and reentry program lists attached).
Virginia: per state regulations, certain codes are exempt from POS restrictions or allowed in specified POS (examples provided).

POS lists and attachments: A state-specific list of CPT/HCPCS codes with allowed or denied POS is maintained and attached where applicable (see state attachments for exact code/POS combinations).

Coding Guidance and Code Lists

General guidancemixed

Many CPT and HCPCS codes include a Place of Service (POS) in their description or coding guidelines indicating where the code may be performed. Codes not on the payer-specific list have no POS limitation; codes with an appropriate POS may still be subject to other reimbursement policies.

Facility NA — POS exceptions and restrictions (examples)mixed

G0398	Example POS allowance noted in state guidance (see state-specific lists).
G0399	See state-specific POS guidance.
G0400	See state-specific POS guidance.
Q4081	State-specified POS allowances may apply.
G0511	State-specified POS allowances may apply.
J0879	State-specified POS allowances may apply.
M0220	State guidance may restrict POS (example: not allowed in POS 02,10 in some states).
M0221	State guidance may restrict POS (example: not allowed in POS 02,10 in some states).
M0201	State guidance may restrict POS (example: not allowed in POS 02,10,12 in some states).
90480	State guidance may restrict POS (example: not allowed in POS 12 in some states).

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Non-Facility NA Indicator Rule

Non-Facility NA Indicator

Facility NA Indicator Rule — Professional claim POS 21

Facility NA Indicator 'NA'

Key Terms and Indicators

Place of Service (POS) definition

DefinitionPlace of Service (POS) are two-digit codes submitted on the CMS 1500 or electronic equivalent to indicate the setting in which a service was provided.

MaintenancePOS codes are maintained by the Centers for Medicare & Medicaid Services (CMS).

Use in claimsUnitedHealthcare aligns with the CMS POS code set and requires appropriate POS reporting for CPT/HCPCS reimbursement.

Non-Facility NA — definition and implication

DefinitionNon-Facility NA indicates the procedure is 'rarely or never performed in the non-facility setting' per the CMS National Physician Fee Schedule Relative Value File.

Reimbursement implicationUnitedHealthcare will not consider for reimbursement CPT and HCPCS codes with Non-Facility NA when reported without an appropriate POS.

Provider actionSubmit these codes only with the POS appropriate to the code description and UnitedHealthcare's code-to-POS guidance to avoid denial.

Facility NA — definition and implication

DefinitionFacility NA indicates the procedure is 'rarely or never performed in the facility setting' per the CMS National Physician Fee Schedule Relative Value File.

Reimbursement implicationCommunity Plan will not consider for reimbursement CPT and HCPCS codes with Facility NA when reported on a professional claim with facility POS 21.

Provider actionAvoid billing Facility-NA codes on professional claims with POS 21; use the appropriate POS specified by code guidance and UnitedHealthcare lists.

POS codes

DefinitionPOS codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided (CMS-maintained).

Submission fieldSubmitted on the CMS-1500 claim form or electronic equivalent to indicate service setting.

AlignmentUnitedHealthcare aligns reimbursement requirements with the CMS POS code set and uses it to determine appropriate billing settings.

NA indicators

DefinitionNA indicators (NonFacility Indicator 'NA' and Facility NA Indicator 'NA') are flags assigned to CPT/HCPCS codes specifying facility or non-facility applicability used to determine POS applicability.

Use in policyUnitedHealthcare uses these CMS NA indicators, together with code descriptions and its maintained code-to-POS lists, to determine reimbursement eligibility by POS.

Provider impactCodes without these indicators or codes outside the policy scope may be out of scope; providers should reference attachments and UnitedHealthcare lists for allowable POS by code and by state.

What Providers Must Do

Billing Rule

Provider claim submission actions — submit accurate claims with CPT/HCPCS codes reported with an appropriate Place of Service

Submit accurate claims with CPT/HCPCS codes reported with an appropriate Place of Service (POS). Colorado Rocky Mountain Health Plans (following UnitedHealthcare Community Plan guidance) maintains a list of CPT and HCPCS codes and their expected POS; codes not on that list are not POS-limited by this policy. Ensure the POS reported aligns with the code description or coding guidelines — some CPT/HCPCS codes include a POS in their description or are assigned a NonFacility/Facility NA indicator that restricts where they may be billed. Note that reporting a procedure code with an appropriate POS does not waive other applicable reimbursement policies or requirements.

This policy applies to CPT/HCPCS codes that either include a Place of Service in their description or are assigned the NonFacility or Facility NA indicator 'NA'.
For any code not on the payer’s POS list, the place of service is not limited by this policy.
Codes billed with an appropriate POS may still be subject to other reimbursement policies, state regulations, provider contract terms, and benefit design limits.

Note

Scope for provider billing

Scope for provider billing: This policy addresses CPT and HCPCS codes that include a Place of Service in their description or in their coding guidelines and codes assigned the NonFacility Indicator 'NA' and/or Facility NA Indicator 'NA'. Codes that do not meet these criteria, as well as mental health/substance abuse codes and codes addressed in other reimbursement policies, are out of scope. The payer maintains a Medicaid Procedure-to-Place-of-Service list (and state-specific attachments where applicable) that maps codes to allowable POS for Medicaid products. Providers should consult the applicable attachments (e.g., state lists, Medicaid Procedure to POS List, Arizona-specific list, Washington reentry program list) when determining allowable POS.

Applies to services reported on CMS-1500 or electronic equivalent.
Includes codes with POS in their CPT/HCPCS description or codes with NonFacility/Facility NA indicators.
Excludes codes not meeting the above criteria and codes covered under other reimbursement policies.

Denial Risk

State exceptions and POS restrictions

State exceptions and POS restrictions: Certain states impose exceptions or specific POS allowances/denials. Providers must follow state-specific guidance and the payer’s attachments for state rules. Examples of state-specific rules retained by the source include:

Texas: Texas Medicaid allows specific codes in particular POS (e.g., G0398/G0399/G0400 in POS 11; Q4081 in multiple POS) and explicitly does not allow certain codes in listed POS; HHSC/Medicaid denies all CPT/HCPCS codes billed in POS 09. Refer to the Texas attachment for full details.
Virginia: Per state regulations, certain codes are exempt from POS restrictions (e.g., H0035 in POS 22, 23, 49, 53 & 99) and other specified allowances apply (e.g., some codes allowed for pharmacists in POS 01).
Washington: Washington State guidance includes multiple exemptions and POS allowances (examples: specific evaluation/management and G-codes allowed in POS 04 & 12; some codes payable in POS 09 or POS 27; certain behavioral health codes billable in any POS). A Washington Medicaid Reentry Program list identifies codes allowable in POS 09.
Other states: Additional state-specific POS constraints and exceptions are maintained in the payer’s state attachments. Always consult the state attachment applicable to the member’s coverage for definitive POS rules.

OpenPayer

Procedure and Place of Service (POS) reimbursement

Place-of-Service Reimbursement Criteria

Coding Guidance and Code Lists

Key Terms and Indicators

What Providers Must Do