Hemoglobin A1C testing reimbursement and frequency limits
Defines UnitedHealthcare Community Plan reimbursement and frequency limits for hemoglobin A1C (diabetes mellitus) testing billed on CMS-1500 or UB-04 forms for Medicaid products and affected providers.
No material clinical or coverage changes in this revision.
Coverage Criteria for Hemoglobin A1C Testing
Coverage criteria for hemoglobin A1C testing
UnitedHealthcare will consider reimbursement for listed hemoglobin A1C procedure codes under the following conditions and frequency limits:
ALL of the following
- Type 1 Diabetes mellitus
- Type 2 Diabetes mellitus
ALL of the following
- Reimbursement is allowed once every three months (90 consecutive calendar days) per member regardless of billing or rendering provider (any individual provider or any facility).
ALL of the following
- Applies to UnitedHealthcare Community Plan Medicaid products and to services reported using UB-04, CMS-1500 or electronic equivalents; applies to network and non-network providers including hospitals, ambulatory surgical centers, physicians and other qualified professionals.
ALL of the following
- UnitedHealthcare will consider reimbursement of either hemoglobin A1C procedure code once every three months when billed for the listed diabetes mellitus conditions; if billed with other conditions, reimbursement may be considered but the once-every-three-months limitation does not apply.
ALL of the following
- Certain states are exempt from this policy per the policy's state exceptions list; see policy for specific states.
Procedure Codes and Frequency Limits
Prior Authorization and Billing Notes
Prior authorization and reimbursement note — A1C testing frequency limit
UnitedHealthcare will consider reimbursement for hemoglobin A1C procedure codes 83036 and 83037 when billed for Type 1 or Type 2 diabetes mellitus. Reimbursement is allowed once every three months (90 consecutive calendar days) per member regardless of billing or rendering provider; billing either CPT code counts toward the same limit.
- Applies when billed for Type 1 or Type 2 diabetes mellitus (frequency limitation applies only for these conditions).
- Frequency limit: one reimbursement per member once every three months (90 consecutive calendar days), regardless of billing or rendering provider.
- Either procedure code (83036 or 83037) counts toward the same three-month limit.
Scope, Forms, and Frequency Definitions
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.