CurrentUnitedHealthcarePolicy 2025ROI11B

CMS 1500 Reimbursement Policy (modifier guidance)

Governs UnitedHealthcare reimbursement rules for services billed on the CMS-1500 form (and electronic equivalent) including modifier usage guidance for UnitedHealthcare Commercial and Individual Exchange plans and all network and non-network providers.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Reimbursement Policy (modifier guidance)

Policy CodePolicy 2025ROI11B

Change TypeModifier table additions/removals (historical)

Effective Date

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Added Modifiers RI, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, 50 to Modifier Reference Tables and Modifiers addressed within the reimbursement policy section.

Removed modifier TW and removed policy Durable Medical Equipment; Orthotics and Prosthetics Multiple Frequency History Section.

Updated Application section to indicate this Reimbursement Policy applies to: All Individual Exchange benefit plans.

Added Modifiers GC, GE, FS, FT to Modifier Reference Tables and added Services by Residents, Interns and Medical Students to reimbursement policy section.

CMS-1500claim form governed by this policy

Commercial & Exchangeplans covered

Facility claimSG stance

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Scope, Billing and Reimbursement Rules

Scope and billing rules

Scope and a specific reimbursement treatment example:

Applies to services reported on the CMS-1500 form (or electronic equivalent) for all products and all network and non-network physicians and other qualified health care professionals.

If a CMS-1500 claim is submitted with modifier SG, treat the submission as a facility claim (not a professional claim) and it is not subject to UnitedHealthcare's professional reimbursement policies.

CMS-1500 modifier billing rules

Treatment of certain CMS-1500 submissions and non-reimbursable modifiers.

If a CMS-1500 claim is submitted with modifier SG, treat the submission as a facility claim (not a professional claim) and it is not subject to UnitedHealthcare's professional reimbursement policies.

Non-reimbursable modifiers: Modifiers listed as not reimbursable to healthcare professionals include: 27, 73, 74, PO, H9, HU, HV, HW, HX, HY, HZ, QJ, SE, SL, TR.

Modifier Reference & Non-reimbursable Modifiers

Modifiers referencedCPT

22	Increased Procedural Services — referenced to Anesthesia, Obstetrical, Robotic Assisted Surgery and other policies
25	Significant, Separately Identifiable E/M service on same day — referenced to multiple policies (CCI editing, global days, injections, preventive, prolonged services)
59 / XU / XE / XS / XP	Distinct Procedural Service modifiers — cross-referenced to many topics including CCI editing, MPPR, rebundling, laboratory services
95	Telehealth/Virtual Health — referenced to Telehealth/Virtual Health and Provider Based Billing
SG	Indicates facility services when submitted on CMS-1500

Modifiers referencedModifier

SG	Modifier indicating facility services when submitted on CMS-1500
GC	Modifier added to reference tables (services by residents/interns/students)
GE	Modifier added to reference tables (services by residents/interns/students)
FS	Modifier added to reference tables
FT	Modifier added to reference tables
RI/RT/LT/E1-E4/FA/F1-F9/TA/T1-T9/50	Multiple modifiers added to Modifier Reference Tables as of 1/1/2025

Non‑reimbursable modifiers (excerpt)

Examples of non-reimbursable modifiers27, 73, 74, PO, H9, HU, HV, HW, HX, HY, HZ, QJ, SE, SL, TR

ContextListed under 'Services and Modifiers Not Reimbursable to Healthcare Professionals' in the modifier reference tables.

ApplicabilityApplies to services billed to UnitedHealthcare Commercial and Individual Exchange plans as noted in the CMS-1500 reimbursement policy (2025ROI11B).

Provider Billing Actions & Special Handling

Billing Rule

SG-modified CMS-1500 treated as facility claim

When a CMS-1500 claim is submitted with modifier SG, the SG modifier indicates facility services; the submission is treated as a facility claim and is not subject to UnitedHealthcare's reimbursement policies for professional claims.

Billing Rule

Ambulatory Surgical Center (SG) — facility reimbursement treatment

Services reported on a CMS-1500 form with an SG modifier are not treated as professional claims. The SG modifier denotes facility services and such submissions are processed as facility claims and are not subject to UnitedHealthcare's professional reimbursement policies.

Key Terms

Modifier — definition

DefinitionA modifier is a reporting mechanism indicating that a service or procedure was altered by specific circumstances without changing the code definition.

PurposeProvides additional information such as repeat performance, unusual events, multiple providers, or multiple locations.

GuidanceRefer to the Procedure to Modifier Policy and individual CPT/HCPCS guidance for appropriate use with specific procedure codes.

SG modifier — definition

Meaning of SGIndicates facility services when submitted on a CMS-1500 form; such submissions are treated as facility claims, not professional claims.

Reimbursement treatmentClaims with SG submitted on CMS-1500 are not subject to UnitedHealthcare's professional reimbursement policies and are processed as facility claims.