CurrentOptumPolicy N/A

Non-covered health services (reimbursement exclusions)

Defines services that do not meet the definition of a covered health service for claims billed on CMS 1500, electronic 837p/837i submissions, and provider portals for Optum-administered behavioral health benefit plans and related Commercial products.

Policy Summary

PayerOptum

PolicyNon-covered health services (reimbursement exclusions)

Policy CodePolicy N/A

Change TypeOperational — Non-covered code list updates

Effective Date

Next Review Date

Key ActionCheck member-specific benefit plan documents and any federal/state mandates before applying this guideline; ensure accurate claim submission.

SourceLink

POLICY UPDATE CHANGES

Added codes to Non-Covered HCPC Code List (May, 2025).

Added S9470 and C7901 to Non-Covered Code list (February, 2025).

Added A4543 and E0721 to Non-covered code list (October, 2024).

Updated Non-covered Code list and added G2211 (March, 2024).

Clarification on H0033; removed G0469 & G0470 (June, 2020).

CMS 1500, 837p, 837i, UB-04claim form types referenced

Behavioral health plansprimary plan focus

Non-Covered HCPC Code Listseparate attachment maintained and updated

Member-specific review requiredbenefit document dependency

Coverage determination and exclusions

Exclusions and determination of Covered Health Services are based on benefit documents, clinical evidence, and plan exclusions.

Providers must verify member-specific benefit plan documents and any applicable federal or state mandates to determine whether a service is a Covered Health Service; review of the member-specific benefit document is required.

See provider responsibilities for required pre-checks.

A Covered Health Service is one that is provided for the purpose of preventing, diagnosing, or treating a sickness, injury, mental illness, substance use disorder, or their symptoms; and is described as Covered in the member’s plan and not excluded.

Definition follows Certificate of Coverage language.

Services that do not meet the definition of a Covered Health Service or that are not listed as Covered in the member-specific benefit document are excluded from coverage.

The absence of a specific exclusion does not imply coverage.

Policy Summary

PayerOptum

PolicyNon-covered health services (reimbursement exclusions)

Policy CodePolicy N/A

Change TypeOperational — Non-covered code list updates

Effective Date

Next Review Date

Key ActionCheck member-specific benefit plan documents and any federal/state mandates before applying this guideline; ensure accurate claim submission.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Code lists and coding requirements

Non-covered HCPC/HCPCS codesHCPCSNot Covered

Non-Covered HCPC Code List	Separate attachment listing HCPC/HCPCS codes that are non-covered; updated periodically (see history).
S9470	Added to Non-Covered Code list (February, 2025).
C7901	Added to Non-Covered Code list (February, 2025).
A4543	Added to Non-covered code list (October, 2024).
E0721	Added to Non-covered code list (October, 2024).
G2211	Added to Non-covered Code list (March, 2024).

Coding accuracy — requirements

RequirementClaims must be submitted using procedure code(s) that correctly describe the health care services provided.

Reimbursement basisReimbursement is based on the procedure code(s) submitted that accurately describe services provided.

Applicable form typesApplies to services billed on CMS 1500, UB-04, and electronic submissions (837p, 837i) and provider portals where specified.

Glossary and foundational terms

Covered Health Service — definition

Definition (2001)Health services provided for the purpose of preventing, diagnosing or treating a Sickness, Injury, mental illness, substance abuse, or their symptoms; described as Covered in plan documents and not excluded.

Definition (2007)Services, supplies, or Pharmaceutical Products that are provided for preventing/diagnosing/treating, consistent with nationally recognized scientific evidence and prevailing medical standards, not for convenience, described in the Certificate of Coverage, and not otherwise excluded.

ApplicationServices that do not meet the definition of a Covered Health Service or are not listed as Covered in the member specific benefit plan document are excluded.

Scientific evidence / Prevailing medical standards — definition

Scientific evidenceMeans results of controlled clinical trials or other studies published in peer-reviewed medical literature generally recognized by the relevant medical specialty community.

Prevailing medical standards and clinical guidelinesMeans nationally recognized professional standards of care, including national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines.

Use in determinationsClinical protocols describing the scientific evidence and prevailing standards are maintained and used to support coverage determinations; protocols are available to Covered Persons on Live and Work Well and to clinicians on UnitedHealthcareOnline.

OpenPayer

Non-covered health services (reimbursement exclusions)

Coverage determination and exclusions

Code lists and coding requirements

Provider responsibilities and required checks

Glossary and foundational terms