CurrentColorado Rocky Mountain Health PlansPolicy 2026R0127A

Procedure and Place of Service reimbursement for CMS 1500 claims

This policy governs reimbursement for CPT and HCPCS codes billed on the CMS-1500 (or electronic equivalent) based on whether the Place of Service (POS) reported is appropriate for the code; it applies to UnitedHealthcare Commercial and Individual Exchange plans and all network and non-network physicians and qualified health care professionals.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyProcedure and Place of Service reimbursement for CMS 1500 claims

Policy CodePolicy 2026R0127A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate CMS-1500 claims using correct CPT/HCPCS codes and appropriate Place of Service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form this policy applies to

Commercial & Individual Exchangeplan types covered

NA referencedNA indicator enforcement

Code & POS listsattachments included

Place of Service Reimbursement Criteria

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Place of Service reimbursement criteria

Reimbursement is allowed only when the Place of Service (POS) reported is appropriate for the CPT/HCPCS code based on the code description, coding guidance, or CMS NPFS indicators.

Reimbursement is allowed only when the POS reported is appropriate for the code per code description, coding guidelines, or CMS NPFS indicators.

ALL of the following

If a CPT/HCPCS code's description or coding guidance specifies allowed POS, UnitedHealthcare will reimburse only when the submitted POS matches those allowed locations.
Refer to the policy attachments for the maintained list of codes and their appropriate places of service; attachments are periodically updated.

ALL of the following

Codes assigned the NonFacility Indicator 'NA' in the CMS National Physician Fee Schedule (NPFS) will not be reimbursed when reported on a professional claim without an appropriate (facility) POS; the 'NA' indicates the procedure is rarely or never performed in the non-facility setting.
Codes assigned the Facility NA Indicator 'NA' in the CMS NPFS will not be reimbursed when reported on a professional claim with facility Place of Service 21; the 'NA' indicates the procedure is rarely or never performed in the facility setting by a physician or qualified health care professional.

UnitedHealthcare may use reasonable discretion in interpreting and applying this policy; legislative mandates, contracts, or benefit design may modify reimbursement outcomes.

Codes and POS-specific Coding Rules

Codes with POS-specific descriptions or coding guidelinesCPT

94002

Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day

CMS NPFS 'NA' indicator enforcement

NonFacility 'NA' enforcementCodes with the CMS NPFS NonFacility Indicator 'NA' will not be reimbursed when reported on a professional claim without an appropriate (non-facility) Place of Service.

Facility 'NA' enforcementCodes with the CMS NPFS Facility Indicator 'NA' will not be reimbursed when reported on a professional claim with facility Place of Service 21.

Source of indicatorsUnitedHealthcare uses the CMS National Physician Fee Schedule (NPFS) Relative Value File 'NA' indicators to determine enforcement; see policy attachments for the maintained NPFS link.

Effect on reimbursementWhen a code is flagged 'NA' for a setting, UnitedHealthcare will not consider that code for reimbursement if billed in the disallowed POS on CMS-1500 professional claims.

Claims Submission and Denial Risk Guidance

Documentation Required

Submit accurate CMS-1500 claims with correct codes and POS

You are responsible for submission of accurate claims on the CMS-1500 (or electronic equivalent). Submit claims using the correct CPT/HCPCS codes and report the appropriate Place of Service; UnitedHealthcare may use reasonable discretion in interpreting and applying this policy.

Denial Risk

POS-based denial risk — honor CMS NPFS 'NA' indicators

Do not expect reimbursement when CMS NPFS 'NA' indicators restrict a code's setting — codes assigned NonFacility Indicator 'NA' will not be reimbursed when reported on a professional claim without an appropriate POS; similarly, facility-related 'NA' indicators prohibit reimbursement when billed in the disallowed facility POS.

NonFacility Indicator 'NA' means the procedure is rarely or never performed in the non‑facility setting and will not be considered for reimbursement when reported without an appropriate POS (see NPFS).
UnitedHealthcare aligns with CMS POS codes and enforces NPFS 'NA' indicators when determining reimbursement based on reported Place of Service.

Key Definitions

Place of Service

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

Use on claimsProviders must report the appropriate POS on CMS-1500 (or electronic equivalent) claims to support reimbursement per policy.

Alignment with CMS code setUnitedHealthcare aligns POS reporting expectations with the CMS Place of Service code set and uses CMS guidance to assess appropriateness.

Impact on paymentReimbursement is allowed only when the POS reported is appropriate for the CPT/HCPCS code per code description, coding guidelines, or CMS NPFS indicators.