CurrentUnitedHealthcarePolicy 2025R0111B

REIMBURSEMENT POLICY CMS-1500 — Modifier Reference and Reimbursement Guidance

Reference tool for UnitedHealthcare Community Plan Medicaid reimbursement treatment of CPT/HCPCS modifiers on CMS-1500 claims; guides providers on which modifiers are addressed and links to more specific reimbursement policies and an attached Modifier Reimbursement Grid.

Policy Summary

PayerUnitedHealthcare

PolicyREIMBURSEMENT POLICY CMS-1500 — Modifier Reference and Reimbursement Guidance

Policy CodePolicy 2025R0111B

Change TypeReference/Informational

Effective Date

Next Review Date

Key ActionTreat claims submitted with the SG modifier on a CMS-1500 as facility claims; they are not subject to UnitedHealthcare Community Plan professional reimbursement policies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AttachmentModifier Reimbursement Grid

ComprehensiveModifier groups referenced

Community Plan MedicaidPlan applicability

Coverage references and navigation

This document does not itself set full reimbursement rules but directs providers to specific UnitedHealthcare reimbursement policies and an attachment (Modifier Reimbursement Grid) for Medicaid percentage details.

Refer to the specific UnitedHealthcare reimbursement policy that pertains to the coding situation for complete guidance; this document is a reference guide only.

For UnitedHealthcare Community Plan Medicaid reimbursement percentages, consult the attached Modifier Reimbursement Grid (Attachments).

For guidance on appropriate use of modifiers with individual CPT and HCPCS procedure codes, refer to the Procedure to Modifier Policy.

The lists in this document represent modifiers that are addressed in UnitedHealthcare Community Plan reimbursement policies but are not an all-inclusive list of CPT and HCPCS modifiers.

Policy Summary

PayerUnitedHealthcare

PolicyREIMBURSEMENT POLICY CMS-1500 — Modifier Reference and Reimbursement Guidance

Policy CodePolicy 2025R0111B

Change TypeReference/Informational

Effective Date

Next Review Date

Key ActionTreat claims submitted with the SG modifier on a CMS-1500 as facility claims; they are not subject to UnitedHealthcare Community Plan professional reimbursement policies.

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.

Billing guidance and provider impacts

Billing Rule

Ambulatory Surgical Center claims with SG

Services reported on a CMS-1500 form (or electronic equivalent) with an SG modifier are not treated as professional claims. The SG modifier indicates facility services; such claims are processed and reimbursed as facility (Ambulatory Surgical Center) claims and are not subject to UnitedHealthcare Community Plan professional reimbursement policies.

Applies when a claim is submitted on a CMS-1500 (or successor) with modifier SG
Claims with SG are treated as facility/ASC claims, not professional/provider claims
Not subject to UnitedHealthcare Community Plan professional reimbursement policies

Modifier definitions

modifier — definition

DefinitionA modifier provides the means to report that a performed service or procedure was altered by specific circumstances without changing its definition or code; it can convey additional info such as multiple performances, unusual events, multiple providers, or multiple locations.

PurposeUsed to report or indicate that a service was altered by specific circumstances while retaining the original procedure code definition.

Reference guidanceThis document is a reference tool directing readers to specific UnitedHealthcare reimbursement policies and the Procedure to Modifier Policy for appropriate use with individual CPT/HCPCS codes.

Scope noteThe lists in this document represent modifiers addressed in UnitedHealthcare Community Plan reimbursement policies and are not all‑inclusive of CPT/HCPCS modifiers.

Attachment for ratesFor Community Plan Medicaid reimbursement percentages, see the Modifier Reimbursement Grid in the Attachments section.

SG — facility indicator on CMS‑1500

MeaningSG indicates facility services when submitted on a CMS‑1500 (1500 Health Insurance Claim Form) or its electronic equivalent.

Reimbursement treatmentClaims reported with SG on a CMS‑1500 are not treated as professional claims and are processed as facility claims.

Policy applicabilitySuch SG‑flagged claims are not subject to UnitedHealthcare Community Plan reimbursement policies that apply to professional claims.

ContextThis treatment is specified in the Questions and Answers section addressing Ambulatory Surgical Center claims submitted on the CMS‑1500.

24	Used only with E/M services (per AMA); referenced in CCI Editing and Obstetrical Services contexts.
25	Used with E/M codes only; referenced for Preventive Medicine and Screening, Obstetrical Services, injection/infusion, preventive medicine, prolonged services, rebundling and same-day same-service contexts.
59	Distinct procedural services — referenced in Anatomical Modifier Requirement, CCI Editing, MPPR Diagnostic Imaging, Obstetrical Services, Pediatric & Neonatal Critical & Intensive Care Services, Professional/Technical Component and other contexts.

OpenPayer

REIMBURSEMENT POLICY CMS-1500 — Modifier Reference and Reimbursement Guidance

Coverage references and navigation

Modifier examples and coding contexts

Billing guidance and provider impacts

Modifier definitions