CurrentOptumPolicy N/A

Outpatient services reimbursement submission rules (CMS-1500)

Governs submission and reimbursement requirements for outpatient services billed to Optum commercial products, specifying use of the CMS-1500 form and coding expectations for providers and claim types.

Policy Summary

PayerOptum

PolicyOutpatient services reimbursement submission rules (CMS-1500)

Policy CodePolicy N/A

Change TypeClarification and code list revision

Effective DateN/A

Next Review DateOctober, 2025

Key ActionSubmit outpatient services on CMS-1500 with appropriate CPT/HCPCS; UB-04 claims will be denied and must be resubmitted on CMS-1500.

SourceLink

POLICY UPDATE CHANGES

Clarified when supporting documentation is needed.

Additional revenue codes were added (517, 519, 520, 521, 780, 902, 903, 904, 920, 942, 969, 988).

CMS-1500 requiredForm required for outpatient reimbursement (UB-04 denied)

MultipleRepresentative outpatient revenue codes included

All commercialApplies to

CMSAlignment

Outpatient Submission and Reimbursement Rules

Policy Summary

PayerOptum

PolicyOutpatient services reimbursement submission rules (CMS-1500)

Policy CodePolicy N/A

Change TypeClarification and code list revision

Effective DateN/A

Next Review DateOctober, 2025

Key ActionSubmit outpatient services on CMS-1500 with appropriate CPT/HCPCS; UB-04 claims will be denied and must be resubmitted on CMS-1500.

SourceLink

On This Page

Optum aligns with CMS guidelines on outpatient services being rendered by the appropriate certified provider.

Optum will not reimburse independently submitted services by a non-contracted health care practitioner (other than a Physician or Qualified Health Care Professional) unless a state mandate requires reimbursement.

Outpatient services must be submitted on a CMS-1500 (1500 Health Insurance Claim Form) to be considered for reimbursement.

Claims billed on a UB-04 will be denied and must be resubmitted on a CMS-1500 with an appropriate CPT or HCPCS code.

Note: The list of representative revenue codes in this policy is a sample and is not exhaustive; coding methodology, reimbursement logic, regulatory requirements, benefits design and provider contracts may affect reimbursement and can supplement or supersede this policy.

Codes and Form Requirements

Representative outpatient revenue codes (non-exhaustive)Revenue

500	Outpatient Services - General
510	Clinic - General
513	Clinic - Psychiatric
515	Clinic - Pediatric
517	Family Practice Clinic
519	Other Clinic
520	(Description not completed in source)
521	Freestand Clinic
529	Other Freestanding Clinic
780	Telemedicine

1–10 of 28

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Facility-specific/program UB-04 examples (use appropriate program codes)Revenue

905	(Referenced as example program code for facility-based programs in brief)
906	(Referenced as example program code for facility-based programs in brief)
912	(Referenced as example program code for facility-based programs in brief)
913	(Referenced as example program code for facility-based programs in brief)

Form requirement

Required claim formCMS-1500 required for outpatient services; claims billed on UB-04 will be denied

Resubmission requirementUB-04 claims denied must be resubmitted on CMS-1500 with a CPT or HCPCS code

ScopeApplies to outpatient services to be considered for reimbursement (see representative revenue codes)

What Providers Must Do

Billing Rule

Claim submission requirement — use CMS‑1500 with CPT/HCPCS

Submit all outpatient services on the CMS‑1500 (1500 Health Insurance Claim Form) with the appropriate CPT or HCPCS codes; claims submitted on a UB‑04 will be denied and must be resubmitted on a CMS‑1500 with CPT/HCPCS coding.

UB‑04 submissions will be denied and require resubmission on CMS‑1500 with CPT or HCPCS codes.

Definitions and Disclaimers

Outpatient submission and coding

Submission methodOutpatient services must be billed on CMS-1500 (electronic 837p/837i and provider portals accepted)

Coding on CMS-1500Use appropriate CPT or HCPCS procedure codes when submitting outpatient services on CMS-1500

Facility programs exceptionFacility-based programs that require UB-04 should use the appropriate program codes as noted in policy (these are program-specific and separate from standard outpatient submissions)

Coding references and reimbursement

Purpose of CPT/CMS referencesReferences to CPT and CMS are used for definitional purposes in the policy

No guarantee of paymentCPT or other source references do not imply any right to reimbursement

ConsiderationsCoding methodology, reimbursement logic, regulatory requirements, benefits design and provider contracts may affect reimbursement outcomes