CurrentUnitedHealthcarePolicy 2025R7102AB

Reimbursement Policy CMS-1500

Defines UnitedHealthcare Community Plan reimbursement rules for services billed on the CMS-1500 form across Medicaid products and state-specific covered/non-covered code lists; affects network and non-network physicians and other qualified health care professionals submitting CMS-1500 claims.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy CMS-1500

Policy CodePolicy 2025R7102AB

Change TypeNo material changes noted

Effective Date

Next Review Date

Key ActionSubmit a prior authorization request when a non-covered code may be medically necessary for certain states to request coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form governed

Medicaidline of business

Category II not payablecode class stance

state-specificstate attachment frequency

multipleattachment updates

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Coverage Determinations and Exceptions

Coverage rules and exceptions

General coverage determination rules for CPT/HCPCS codes in Medicaid markets.

If a CPT or HCPCS code is not listed on a state's Medicaid fee schedule, the code is considered not covered for that state's Medicaid market unless there is a benefit and/or contractual agreement with negotiated rates.

If a CPT or HCPCS code is on the state fee schedule but not on the CMS National Physician Fee Schedule (NPFS), the code will be covered for that state's Medicaid market but remains subject to all UnitedHealthcare Community Plan reimbursement policies and may deny under other applicable policies.

If a CPT and/or HCPCS code is neither on the CMS NPFS nor on an individual state fee schedule, the code will deny as not covered in that state unless there is a benefit and/or contractual agreement with negotiated rates; codes not covered in any UnitedHealthcare Community Plan market are listed on the UnitedHealthcare Community Plan NonCovered Codes List.

State list behavior: Some Medicaid markets use a Covered Codes List instead of a Non-Covered Codes List; for those states any code not on the Covered Codes List will deny as not covered.

Category II (xxxxF) CPT codes are not payable in UnitedHealthcare Community Plan Medicaid markets.

Exception — prior authorization: A code otherwise considered not covered may be covered if found to be medically necessary through a prior authorization request in certain states (examples include North Carolina and Ohio).

Providers are responsible for submitting accurate claims and should reference state provider manuals; policy is administered based on Date of Service.

Coding Lists and Fee Schedule Rules

Category II codesCPTNot Covered

Category II (xxxxF)

CPT Category II codes identified by procedure code ending with 'F' are used for performance measurement and are not payable in Medicaid markets per this policy.

State fee schedule membership — codes not on state Medicaid fee schedule considered not covered unless exceptions exist

RuleCodes not listed on a state Medicaid fee schedule are considered not covered for that state's Medicaid market unless there is a benefit and/or contractual agreement with negotiated rates.

ImplicationProviders should verify state fee schedule membership before billing; absence on the fee schedule will result in a not covered determination unless an exception applies.

Exception PathContractual or benefit exceptions (negotiated rates) can override the default not covered status for codes not on the state fee schedule.

Provider Requirements and Actions

Prior Authorization

Prior authorization may override non-covered code determinations

Prior authorization may override certain non-covered code determinations in some states. If a service or code is listed as non-covered in state-specific attachments, providers should still submit a prior authorization request when clinical circumstances support medical necessity — the prior authorization determination may result in coverage despite the non-covered listing.

Example: North Carolina — a non-covered code may be covered if found medically necessary through a prior authorization request.

Note

State exceptions update

State-specific exceptions and administration notes have been updated across multiple jurisdictions. Providers must review the State Exceptions and Benefit Considerations to confirm whether a state: utilizes a Covered Codes List, has separate Non-Covered Codes lists administered outside this policy, or has unique coverage rules for specific codes.

Examples: Arizona, Idaho, Indiana, Kansas, Minnesota, Ohio, and others utilize Covered Codes Lists.
Michigan: Non-Covered Codes are not administered by this policy.
Mississippi CHIP (Plan ID MSCHIP) has a separate Non-Covered Codes List.
New Jersey: Code S5151 is covered for New Jersey Medicaid Family Care only.
North Carolina: prior authorization can overturn non-covered status.

Note

Attachment code list updates

Attachments (Covered Codes Lists and Non-Covered Codes Lists) have been updated in recent policy revisions. Providers must consult the attachments for the latest per‑state covered and non‑covered code listings before billing or submitting prior authorization requests.

Recent attachment updates include Covered Codes Lists changes for Arizona, Indiana, Ohio, Texas, Kansas, Minnesota, Washington DC, Wisconsin, and others.
Non-Covered Codes Lists updated for Missouri, Nebraska, New Jersey, Maryland, Mississippi, New York, North Carolina, Virginia, and additional states.
Specific update examples by date are recorded in the policy History/Resources sections — providers should reference those entries for exact effective update timing.

Definitions and Attachment Notes

Category II codes — definition

DefinitionCPT Category II Procedure Codes are identified by a procedure code ending with 'F' (format xxxxF).

PurposeCategory II codes are intended for performance measurement—not for reporting services for payment determination.

Policy StanceCategory II codes are not payable in UnitedHealthcare Community Plan Medicaid markets per this policy.

Experimental or Investigational Services — definition

DefinitionExperimental or Investigational Services are medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications, or devices that are not FDA approved for the proposed use or are subject to institutional review board review for the proposed use.

FDA ConsiderationNot approved by the U.S. Food and Drug Administration to be lawfully marketed for the proposed use qualifies a service as Experimental or Investigational.

IRB ConsiderationServices or devices subject to review and approval by an institutional review board for the proposed use are considered Experimental or Investigational.

Attachments Section — lists of Covered Codes and Non-Covered Codes by state

Section PurposeThe Attachments Section contains state-specific lists of Covered Codes and Non-Covered Codes used to determine coverage and adjudication for each Medicaid market.

Update FrequencyAttachments are updated periodically; history entries document Covered and Non-Covered Codes list updates across multiple dates and states.

ExamplesRecent updates in the Attachments Section include covered and non-covered code list changes for states such as Arizona, Indiana, Ohio, Texas, Minnesota, New Mexico, Missouri, Nebraska, Massachusetts, Maryland, New York, Washington, and others.

State Exceptions — state-specific deviations or additions

DefinitionState Exceptions are state-specific deviations or additions to the general policy that alter coverage rules for that state (example: North Carolina was added to the State Exceptions section).

EffectState Exceptions can add or modify which codes are covered or non-covered for that state's Medicaid market and may change how attachments are applied.

Administrative NoteState Exceptions and related attachment updates are tracked in the Resources/History entries with effective dates to document policy version changes.