CurrentUnitedHealthcarePolicy 2026R9003A

CMS 1500 reimbursement for Medicare Advantage (NPFS status codes)

Defines UnitedHealthcare Medicare Advantage reimbursement rules for services billed on the CMS-1500 (and electronic equivalent), focusing on how Medicare Physician Fee Schedule (NPFS) status indicators affect payment and provider/member liability; applies to network physicians and other qualified health care professionals serving UnitedHealthcare Medicare Advantage members.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 reimbursement for Medicare Advantage (NPFS status codes)

Policy CodePolicy 2026R9003A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProviders must submit accurate claims on the CMS-1500; the provider is responsible for claim accuracy and potential liability when billing codes assigned NPFS status B, I, M, or P.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6NPFS status codes addressed (B, I, M, N, P, T)

CMS-1500Form(s) governed

Category IICategory II treatment

Member held harmlessMember liability stance

Payment and Liability Rules

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Payment and liability criteria for NPFS status indicators

UnitedHealthcare Medicare Advantage payment rules for NPFS status indicators and provider/member liability.

This policy applies to all services billed on the CMS-1500 (or electronic equivalent) for UnitedHealthcare Medicare Advantage products and to network physicians and qualified health care professionals.

UnitedHealthcare Medicare Advantage will not separately reimburse CPT or HCPCS codes assigned status B, I, M, N, or P on the NPFS Relative Value File.

Codes assigned status T have RVUs and payment amounts but are payable only if no other services payable under the physician fee schedule are billed on the same date by the same provider; otherwise T status codes are bundled and not paid separately.

CPT Category II codes are measurement/reporting codes and are for reporting purposes only regardless of M or I status indicators.

If a code with status indicator B, I, M, or P is billed for a member, the Provider will be held liable for the denied service; the member will be held harmless. Codes identified as supplemental benefits for members may be carved out of non-covered status and bypass the global denial.

NPFS Status Indicators and Category II Codes

NPFS status indicatorsmixed

B	Bundled — payment subsumed by related services; RVUs if present are not used for Medicare payment
I	Not valid for Medicare purposes — another code used for reporting/payment
M	Measurement — reporting purposes only
N	Non-covered — not covered by Medicare
P	Bundled/Excluded — no RVUs or payment amounts; no separate payment under fee schedule
T	Injections — paid only if no other payable physician fee schedule services billed same date by same provider; otherwise bundled

Category II codesCPT

CPT Category II

Supplemental tracking codes recognized as measurement/reporting codes regardless of NPFS status

Claims Submission Responsibilities

Documentation Required

Claims submission responsibilities (CMS-1500)

Providers must submit accurate claims on the CMS-1500 (or electronic equivalent) so UnitedHealthcare Medicare Advantage reimburses based on the code(s) that correctly describe the services provided. The policy does not include prior authorization notations and applies to all services billed on the CMS-1500 for network physicians and other qualified health care professionals.

Ensure CPT, CMS, or other coding guidelines are used so submitted codes accurately describe the services.
Submit claims on the CMS-1500 form or electronic equivalent as this policy governs those submissions.
Be aware UnitedHealthcare may exercise reasonable discretion in applying the policy and implementations may vary across claims processing systems.

Key Terms

RVU (Relative Value Unit)

DefinitionRelative Value Unit (RVU): The assigned unit value of a particular CPT or HCPCS code — the associated RVU is either from the CMS NPFS Non‑Facility Total value or Facility Total value.

Association with NPFSOnly RVUs associated with NPFS status codes 'A', 'R', or 'T' are used for Medicare payment; other status indicators on the NPFS Relative Value File do not generate Medicare fee‑schedule payment amounts.

Scope on CMS NPFS fileThe NPFS Relative Value File contains RVUs and a fee‑schedule status indicator for more than 10,000 physician services; RVUs support payment adjustments (e.g., assistant at surgery, bilateral surgery).

Facility vs Non‑facilityThe associated RVU value used may be the CMS NPFS Facility Total value or Non‑Facility Total value, depending on the setting reported for the service.

NPFS status indicators (B, I, M, N, P, T)

B — BundledPayment for covered services is bundled into payment for other services; if bundled, RVUs present are not used for separate Medicare payment.

I — InvalidCodes not valid for Medicare purposes; another code is used for reporting/payment and they are not separately payable.

M — MeasurementMeasurement/reporting codes used for performance measurement; treated as reporting only and not separately payable under NPFS.

N — NoncoveredCodes identified as not covered by Medicare and not separately payable under the physician fee schedule.

P — Bundled/ExcludedCodes excluded or bundled from separate payment; no RVUs or payment amounts for separate Medicare fee‑schedule payment.

T — InjectionInjection codes may have RVUs and payment amounts but are payable only if no other payable physician fee‑schedule services are billed on the same date by the same provider; otherwise they are bundled.