CurrentUnitedHealthcarePolicy 2025R9037A

Medicare Advantage CMS 1500 Reimbursement Policy

Governs reimbursement methodology and billing rules for services billed on CMS 1500 forms for UnitedHealthcare Medicare Advantage plans, affecting network physicians and other qualified health care professionals.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage CMS 1500 Reimbursement Policy

Policy CodePolicy 2025R9037A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit appropriate Level II HCPCS codes on CMS-1500; do not separately bill non-specific supply codes 99070/99072 or supplies with J-codes in facility POS 19,21,22,23,24.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS 1500claim form governed

POS 19-24facility POS excluded

A4648/A4650implantable markers covered

99070/99072non-specific supply codes

Q4001-Q4051casting/splint Q codes

Coverage Criteria

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage CMS 1500 Reimbursement Policy

Policy CodePolicy 2025R9037A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit appropriate Level II HCPCS codes on CMS-1500; do not separately bill non-specific supply codes 99070/99072 or supplies with J-codes in facility POS 19,21,22,23,24.

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.

inv-01: Implantable tissue markers and dosimeters

Implantable tissue markers and dosimeters are separately reimbursable only when billed with specific surgical CPT codes.

Covered when ALL of the following are met:

• HCPCS code A4648 (implantable tissue marker) or A4650 (implantable radiation dosimeter) is billed on the same date of service with at least one of the following physician CPT codes: 19499, 32553, 49411, or 55876.

• Codes A4648 or A4650 are billed on a physician (CMS‑1500) claim.

Note: If A4648 or A4650 are not reported with one of the listed CPT codes, they are not separately reimbursable.

inv-02: Supplies, DME, orthotics, prosthetics, biologicals, and drugs with facility POS exclusion for separate reimbursement

Facility places of service (POS) — supplies, DME, orthotics/prosthetics, biologicals, and drugs — are included in facility payment and are not separately reimbursable when reported on a CMS‑1500 claim.

Not separately reimbursable when ALL of the following are true:

• The item is a supply, DME, orthotic, prosthetic, biological, or drug reported with a HCPCS J‑code or other HCPCS supply code.

• The item is reported on a CMS‑1500 claim form by a physician or other qualified health care professional.

• The service was provided in one of the following facility POS: 19 (Off-campus outpatient hospital), 21 (Inpatient hospital), 22 (Outpatient hospital — different clinic), 23 (Emergency room — hospital), or 24 (Ambulatory surgical center).

Note: These items are considered included in the facility’s prospective payment and therefore are not eligible for separate physician claim reimbursement when the above conditions apply.

inv-03: Supply coding requirements — supply reimbursement rules

Supply reimbursement rules and specific coding requirements for supplies and supply‑related CPT codes.

An appropriate Level II HCPCS code must be submitted for reimbursement of covered medical and surgical supplies; non‑specific CPT supply codes are not separately reimbursable.

• CPT 99070 and 99072 (non‑specific supplies and materials) are not separately reimbursable in any setting.

• HCPCS codes A4570, A4580, and A4590 (previously used for splints and casts) are invalid for Medicare; providers must use the Q‑codes (Q4001–Q4051) for casting and splint supplies.

Operational note: Do not submit 99070/99072 or invalid A‑series supply codes for separate payment; instead report the appropriate Level II HCPCS or Q‑code as applicable.

Coding and Billing Rules

Implantable markers/dosimetersHCPCSCovered

A4648	Implantable tissue marker
A4650	Implantable radiation dosimeter

Supply and casting codesHCPCSNot Covered

99070	Supplies and materials, except spectacles, provided by the physician over and above those usually included
99072	Non-specific supply code
A4570	Invalid for Medicare (splint/cast supplies)
A4580	Invalid for Medicare (splint/cast supplies)
A4590	Invalid for Medicare (splint/cast supplies)
Q4001-Q4051	Q codes for casting and splint supplies

Place of Service rule — facility POS exclusion

RuleSupplies, DME, orthotics, prosthetics, biologicals, and drugs reported with a HCPCS J code are not separately reimbursable when submitted on a CMS-1500 claim form for facility places of service POS 19, 21, 22, 23, and 24.

RationaleFacility payments under CMS Prospective Payment System and ASC payment system deem drugs and supplies included in facility payment; therefore separate reimbursement to physicians on CMS-1500 is not allowed.

Applicable claim formCMS 1500

Affected submittersPhysicians and other qualified health care professionals submitting CMS-1500 claims for services performed in facility POS listed above.

Definitions

NPFS Relative Value File (NPFS)

TermNational Physician Fee Schedule (NPFS) Relative Value File

ContentsPublic use file containing services covered by the Medicare Physician Fee Schedule, associated Relative Value Units (RVUs), fee schedule status indicators, and payment policy indicators.

PurposeProvides RVUs and payment policy data used to determine physician payment under CMS NPFS.

Relative Value Units (RVU) and Practice Expense (PE RVU)

RVU definitionRelative Value Units (RVUs) = the assigned unit value of a particular CPT or HCPCS code (from CMS NPFS Facility or Non‑Facility totals).

PE RVU definitionPractice Expense (PE) RVU = portion of the total RVUs assigned to a CPT/HCPCS code for practice maintenance costs including rent, equipment, supplies, and non‑physician staff.

Use in policyUnitedHealthcare Medicare Advantage bases HCPCS reimbursement methodology on NPFS RVUs and PE RVUs for CMS‑1500 billed services.

OpenPayer

Medicare Advantage CMS 1500 Reimbursement Policy

Coverage Criteria

Coding and Billing Rules

Provider Actions and Requirements

Definitions