CurrentUnitedHealthcarePolicy 2026R9029A

CMS 1500 Place of Service (POS) reimbursement

Governs reimbursement rules for CPT and HCPCS codes billed on the CMS 1500 form with respect to appropriate Place of Service (POS) reporting for UnitedHealthcare Medicare Advantage providers.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Place of Service (POS) reimbursement

Policy CodePolicy 2026R9029A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate CMS 1500 claims and report the code(s) that correctly describe services provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

all CMS 1500Form scope

CMS POS setCoding alignment

excludes NANA indicator handling

since 6/1/2018Implementation date (history)

Place of Service Reimbursement Criteria

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UnitedHealthcare Medicare Advantage will reimburse codes when the reported Place of Service (POS) is appropriate per the code description, coding guidelines, and the CMS POS Code Set. Codes identified with the NPFS Facility NA indicator 'NA' will not be reimbursed when reported without an appropriate POS.

ALL of the following

ALL of the following
- Reimburse CPT/HCPCS only when POS reported is appropriate for the code per the CPT/HCPCS description or coding guidelines and the CMS POS Code Set.
  UnitedHealthcare Medicare Advantage aligns with the CMS POS Code Set (two-digit POS codes submitted on the CMS 1500 form).
ALL of the following
- Do not reimburse CPT/HCPCS codes that have the NPFS Facility NA indicator 'NA' when reported without an appropriate POS.
  UnitedHealthcare Medicare Advantage will not reimburse codes with the NA indicator when reported without an appropriate POS; exclusions include procedures reported with modifiers 26 or 54-58 as noted.
ALL of the following
- This policy applies to physicians and other qualified health care professionals billing on the CMS 1500 (or electronic equivalent).
  Applies to all Medicare Advantage products and services reported using the 1500 Health Insurance Claim Form.

Examples/clarifications

Codes that include POS in their description or coding guidelines should be reported only in the specified POS (e.g., CPT 94002 is not appropriate for office or home POS because its description identifies hospital inpatient or observation).
See code description or coding guidelines for specified place(s) of service.

Code-Specific POS Guidance

Codes with POS-specific descriptionsCPT

94002

Example code not appropriate for office or home POS because description identifies hospital inpatient or observation

NPFS Facility NA Indicator — not reimbursed without appropriate POSmixedNot Covered

NA-indicator

NPFS Facility NA Indicator 'NA' — procedures rarely or never performed in facility setting; not reimbursed when reported without an appropriate POS

inv-04: POS validity

POS validityCodes reimbursed only when reported with an appropriate POS aligned to the CMS POS Code Set (two-digit POS codes on the CMS 1500).

AlignmentUnitedHealthcare Medicare Advantage aligns POS expectations with the Centers for Medicare & Medicaid Services (CMS) POS Code set.

Claim formPOS must be submitted on the CMS 1500 Health Insurance Claim Form or its electronic equivalent.

NA-indicator exclusionProcedures with NPFS Facility NA indicator 'NA' are not reimbursed when reported without an appropriate POS.

Provider Responsibilities and Monitoring

Documentation Required

Claims submission responsibility

You are responsible for submission of accurate claims on the CMS 1500 form and must report the code(s) that correctly describe the health care services provided.

Ensure claims are submitted on the CMS 1500 (or electronic equivalent) form.
Report the CPT, HCPCS or other codes that correctly describe the services rendered.

Note

Policy updates and monitoring

UnitedHealthcare Medicare Advantage may modify this reimbursement policy at any time to comply with changes in CMS policy and national coding guidelines; providers should monitor CMS and local carrier updates for changes.

Refer regularly to CMS and your local carrier website for policy and billing updates.
Sign up for CMS or local carrier distributions for policy or regulatory changes.

Key Terms

inv-07: Definition — Place of Service

DefinitionA two-digit code used on health care professional claims to indicate the setting in which a service was provided.

UsageReported on the CMS 1500 form or electronic equivalent to indicate service setting.

SourceDefined in the CMS National Physician Fee Schedule Relative Value File as referenced by UnitedHealthcare Medicare Advantage.

inv-08: Definition — National Physician Fee Schedule Relative Value File

DefinitionA public use file that contains information on services covered by the Medicare Physician Fee Schedule, including status and payment policy indicators.

ContentsIncludes associated RVUs, fee schedule status indicators, and payment policy indicators (e.g., assistant at surgery, team surgery, bilateral surgery).

RelevanceUsed to identify the NPFS Facility NA indicator ('NA') which guides reimbursement exclusions when POS is not appropriate.