CurrentColorado Rocky Mountain Health PlansPolicy N/A

Reimbursement for services by residents, interns, and medical students

Governs how UnitedHealthcare Community Plan Medicaid reimburses (or does not reimburse) services rendered by Residents, Interns, and Medical Students and claim submission requirements for licensed physicians billing for those services. Affects providers submitting CMS-1500/UB04 claims to UnitedHealthcare Community Plan Medicaid products.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for services by residents, interns, and medical students

Policy CodePolicy N/A

Change TypeNon‑material updates to Definitions and state exceptionspolicy implemented 2022-01-01

Effective DateJan 1, 2022

Next Review DateN/A

Key ActionWhen billing for services by residents or interns, append modifier GC or GE and ensure the teaching physician personally documents performance or presence during key portions of the service.

SourceLink

POLICY UPDATE CHANGES

Definitions section updated.

State exceptions section updated (Idaho added; Kentucky removed; Tennessee and Arizona removed at earlier dates).

Policy implemented by UnitedHealthcare Community Plan on 2022-01-01.

CMS 1500form(s) to which policy applies

390200000Xtaxonomy code for medical students

GC, GEmodifiers accepted

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Coverage Criteria for Trainee Services

Coverage criteria for trainee services

Covered when the following conditions about provider taxonomy, billing modifiers, and teaching physician documentation are met:

Coverage determination for services rendered by trainees is governed by provider taxonomy, modifier use, and teaching physician documentation requirements.

Services reported with the medical student taxonomy code 390200000X (Student in an Organized Health Care Education/Training Program) will not be reimbursed.

Taxonomy code reported in CMS-1500 Box 24J or electronic equivalent.

Licensed physician billing options

A licensed practicing physician may bill for services rendered by a Resident or Intern when the claim is appended with modifier GC (service performed in part by a Resident under the direction of a Teaching Physician).
A licensed practicing physician may bill for services rendered by a Resident or Intern when the claim is appended with modifier GE (service performed by a Resident without the presence of a Teaching Physician under the Primary Care Exception).

Teaching physicians must personally document that they performed the service or were physically present during key or critical portions of the service; without such documentation, reimbursement will not be made.

If a teaching physician was not involved with any part of the patient’s care, no payment will be made for services furnished by an unlicensed resident/intern, except when allowed under the Primary Care Exception and reported with modifier GE.

Claims must be submitted on CMS-1500 (or electronic equivalent) and use the NUCC taxonomy codes exactly as assigned; this policy applies to UnitedHealthcare Community Plan Medicaid products.

Coding and Taxonomy Guidance

Medical student taxonomymixedNot Covered

390200000X

Student in an Organized Health Care Education/Training Program (NUCC taxonomy)

Reimbursement for services by taxonomy

Medical student taxonomy (NUCC)390200000X — Student in an Organized Health Care Education/Training Program (reported in CMS-1500 Box 24J or electronic equivalent)

Reimbursement policyServices identified by the medical student taxonomy code (390200000X) will not be reimbursed by UnitedHealthcare Community Plan (consistent with CMS)

Claim reporting requirementTaxonomy codes must be used exactly as assigned in the NUCC taxonomy list when reported on claims

Claim Submission and Modifier Requirements

Documentation Required

Claim submission and documentation requirements for resident/intern services

Claims for services rendered by Residents and Interns must be submitted by a licensed practicing physician with documentation from the teaching physician that personally documents their performance or physical presence during key or critical portions of the service; the teaching physician may refer to the resident's documentation but must include independent documentation that corresponds to the resident's notes. Without such teaching physician documentation, no reimbursement can be made.

Submit claims on CMS‑1500 (or electronic equivalent) billed by the licensed practicing physician.
Include independent documentation from the teaching physician that documents performance or physical presence during key/critical portions of the service.
A teaching physician's statement is required even if referring to the resident’s documentation; absence of documentation prevents reimbursement.

Key Definitions

Intern

RoleIntern — an individual who is a doctor but may only practice medicine with guidance and supervision; sometimes referred to as a first‑year resident.

Practice contextIncluded in guidance on resident/intern billing and supervision requirements for GME settings.

Payment implicationServices by interns are subject to the same documentation and teaching physician presence rules as residents for reimbursement consideration when billed by a licensed physician with appropriate modifiers.

Resident

RoleResident — an individual who participates in an approved graduate medical education (GME) program or a physician authorized to practice only in a hospital setting.

GME contextAppears in policy definitions governing when residents may function as primary caregivers and when faculty must be physically present.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for services by residents, interns, and medical students

Policy CodePolicy N/A

Change TypeNon‑material updates to Definitions and state exceptionspolicy implemented 2022-01-01

Effective DateJan 1, 2022

Next Review DateN/A

SourceLink

On This Page

Billing Rule

Modifier guidance for resident services (GC, GE)

Use modifier GC when the service was performed in part by a resident under the direction of a teaching physician, and use modifier GE when the service was performed by a resident without the presence of a teaching physician under the Primary Care Exception; claims for these services will be considered for reimbursement when appended with the appropriate modifier.

Modifier GC — "This service has been performed in part by a Resident under the direction of a Teaching Physician."
Modifier GE — "This service has been performed by a Resident without the presence of a Teaching Physician under the Primary Care Exception."
Primary Care Exception applies when the resident is the primary caregiver and the faculty physician serves a consultative role, permitting resident services without physical presence.

Billing implicationServices furnished by residents require appropriate teaching physician documentation or applicable modifier (GC or GE) when billed by a licensed physician for reimbursement consideration.

Medical Student

RoleMedical Student — an individual enrolled in an organized health care education/training program leading to a degree, certification, registration, and/or licensure.

Taxonomy code390200000X — Student in an Organized Health Care Education/Training Program (NUCC)

Claim reportingThis taxonomy code is reported on the CMS‑1500 claim in Box 24J (servicing provider) or the electronic equivalent.

Teaching Physician

DefinitionTeaching Physician — a physician, other than an intern or resident, who involves residents in the care of their patients.

Presence requirementGenerally must be present during all critical or key portions of the procedure and immediately available to furnish services during the entire service for it to be payable.

Supervisory roleResponsible for documentation that they performed the service or were physically present during key portions as required for reimbursement.

Primary Care Exception

DefinitionPrimary Care Exception — an exception within an approved GME program that applies when the resident is the primary caregiver and the faculty physician sees the patient only in a consultative role.

Program applicabilityApplies to residency programs with requirements incompatible with a physical presence requirement to allow residents to learn medical decision making.

Billing consequenceResident services under the Primary Care Exception may be furnished without the teaching physician physically present; billing must follow modifier and documentation guidance.

Physically Present

MeaningPhysically Present — the teaching physician is located in the same room (or partitioned/curtained area) as the patient or performing face‑to‑face service.

RelevancePhysical presence is a key determinant of whether teaching physician supervision requirements are met for payment purposes.

DocumentationTeaching physicians must document presence during key portions of the service to support reimbursement when required.