CurrentUnitedHealthcarePolicy 2026R0006D

CMS-1500 Supply and HCPCS Reimbursement Policy

Governs UnitedHealthcare reimbursement methodology for supplies, drugs, DME, orthotics, prosthetics and related HCPCS/HCPCS J-codes reported on the CMS-1500 form (and electronic equivalent); applies to Commercial and Individual Exchange plans and to physicians and other qualified health care professionals submitting CMS-1500 claims. Does not apply to Home Health Care and DME providers billing POS 12 for home.

Policy Summary

PayerUnitedHealthcare

PolicyCMS-1500 Supply and HCPCS Reimbursement Policy

Policy CodePolicy 2026R0006D

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit accurate claims using the CMS-1500 form or electronic equivalent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form scope

19,21-24facility POS included

31,32SNF/NF POS

A4570–A4590,99070non-reimbursable codes

Reimbursement and Coverage Criteria

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Reimbursement criteria

UnitedHealthcare reimbursement rules for HCPCS supplies and related items billed on CMS-1500:

Supplies are not separately reimbursable when provided the same day as an E/M service and/or procedure performed in a non-facility place of service; their cost is considered included in the E/M or procedure reimbursement.

Non-facility POSs include 1,3,4,9,11,13,14,15,16,17,20,27,33,49,50,54,55,57,60,62,65,71,72,81,99.

In facility places of service 19, 21, 22, 23 and 24, costs for supplies, DME, orthotics, prosthetics, biologicals and drugs are included in the facility Prospective Payment System (PPS) payment and are not separately reimbursable on CMS-1500 claims submitted by physicians or other qualified health care professionals.

In skilled nursing facility (POS 31) and nursing facility (POS 32), payment for certain DME, orthotics, prosthetics and related supplies is considered included in the facility payment and these items are not reimbursed separately when reported by a physician or other qualified health care professional on a CMS-1500 claim form.

HCPCS codes A4648 and A4650 (implantable tissue markers and implantable radiation dosimeters) are separately billable and payable only when reported on the same date of service with CPT codes 19499, 32553, 49411, or 55876 on a physician services claim; otherwise they are not separately reimbursable (including when reported in a facility setting).

Local anesthetic agents reported using J3490 (unclassified drugs) or J3590 (unclassified biologics) billed with procedures in the CPT range 10000–69999 in POS 11 are integral to the procedure and are not separately reimbursable.

HCPCS L8680 (implantable neurostimulator electrode) is denied in all facility places of service because it is considered included in the facility reimbursement; L8680 is also denied in non-facility when reported with CPT 63650 because the electrodes are considered included in the procedure reimbursement.

Submit an appropriate Level II HCPCS supply code for covered medical and surgical supplies; CPT codes 99070 and 99072 are non-specific and are not reimbursable in any setting.

HCPCS, CPT and Coding Guidance

Casting and Splint SuppliesHCPCSNot Covered

A4570	Casting/splint supply - not reimbursable (invalid for Medicare); use Q-codes
A4580	Casting/splint supply - not reimbursable (invalid for Medicare); use Q-codes
A4590	Casting/splint supply - not reimbursable (invalid for Medicare); use Q-codes
Q4001-Q4051	Temporary Q-codes to reimburse casting and splint supplies

Implantable Tissue Markers and DosimetersHCPCS

A4648	Implantable tissue marker - separately reimbursable when billed with specific CPTs
A4650	Implantable radiation dosimeter - separately reimbursable when billed with specific CPTs

Unclassified Drugs/Biologics (local anesthetic agents)HCPCSNot Covered

J3490	Unclassified drugs - local anesthetic agents not separately reimbursable when billed in POS 11 with procedures 10000-69999
J3590	Unclassified biologics - not separately reimbursable under same conditions as J3490

Implantable Neurostimulator ElectrodeHCPCSNot Covered

L8680

Implantable neurostimulator electrode - denied in facility places of service and denied in non-facility when reported with CPT 63650

Non-specific Supply CPT CodesCPTNot Covered

99070	Non-specific supplies CPT code - not reimbursable
99072	Non-specific supplies CPT code - not reimbursable

General Guidancemixed

POS 11 with CPT 10000-69999	Procedures where local anesthetic agents reported with J3490/J3590 are considered integral to the procedure and not separately reimbursable
Facility POS 19,21,22,23,24 and SNF/NF POS 31,32	Supplies, DME, orthotics, prosthetics, biologicals and drugs reported in these facility places of service are considered included in facility PPS payment and not separately reimbursable on CMS-1500 claims

Procedure range where J3490/J3590 anesthetics are integral

Procedure CPT rangeCPT procedures 10000-69999

HCPCS codes affectedJ3490 (Unclassified drugs) and J3590 (Unclassified biologics)

Place of Service limitationPOS 11 (Office) — when billed with CPT 10000-69999 these anesthetic agents are integral to the procedure and not separately reimbursable

Reimbursement stanceLocal anesthetic agents billed via J3490/J3590 with procedures in this range are not separately reimbursable; cost considered integral to the procedure

Claims Submission and Provider Billing Rules

Documentation Required

Claims submission responsibility

You are responsible for submission of accurate claims using the CMS-1500 (or its electronic equivalent). This policy is intended to ensure reimbursement reflects the code(s) that correctly describe the services provided. UnitedHealthcare may use CPT, CMS, or other coding guidelines for definitional purposes; references do not guarantee reimbursement. The policy applies to services reported on the CMS-1500 (or electronic equivalent) and, when specified, to UB-04 forms. Accuracy of coding and adherence to coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are your responsibility. UnitedHealthcare may interpret and apply this policy with reasonable discretion and may modify the policy at any time by publishing a new version.

Submit claims on the CMS-1500 form or electronic equivalent.
Ensure codes accurately describe the services rendered.
Policy applies to all products and both network and non-network physicians and qualified health care professionals (except where noted for Home Health Care and DME/Orthotics/Prosthetics in POS 12).
UnitedHealthcare may consider other factors (legislation, contracts, benefit documents, other policies) that could supplement or supersede this policy.

Billing Rule

Facility place of service billing rule for supplies/DME/biologicals/drugs

Supplies, durable medical equipment (DME), orthotics, prosthetics, biologicals and drugs reported on a CMS-1500 by a physician or other qualified health care professional are not separately reimbursable when provided in certain facility places of service because those items are considered included in the facility’s global/prospective payment.

No separate reimbursement for specific HCPCS supplies, DME, orthotics, prosthetics, biologicals, and drugs when submitted on a CMS-1500 by any physician or other qualified health care professional for facility POS 19, 21, 22, 23, and 24. See UnitedHealthcare Supply Facility J‑Code Denial Code list and Supply DME Codes in a Facility Setting for affected codes.
Certain DME, orthotics, prosthetics and related supply items on the CMS DMEPOS fee schedule are considered included in payment to skilled nursing facilities (POS 31) and nursing facilities (POS 32) and are not reimbursed separately when reported on a CMS-1500 by a physician or other qualified health care professional.
For purposes of this policy, facility POS = 19, 21, 22, 23, 24; skilled nursing facility = POS 31; nursing facility = POS 32.

Key Definitions

Prospective Payment System (PPS)

DefinitionProspective Payment System (PPS): a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount; payment amounts derived from classification systems (e.g., DRGs).

Implication for supplies/drugsUnder PPS, costs for supplies, DME, orthotics, prosthetics, biologicals and drugs are deemed included in the facility's global payment and are not separately reimbursable on CMS-1500 claims by physicians or other qualified professionals in facility POS.

CMS PPS scopeCMS uses separate PPSs for acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities.

Non-facility place of service — POS values considered non-facility

Non-facility POS listPOS 1, 3, 4, 9, 11, 13, 14, 15, 16, 17, 20, 27, 33, 49, 50, 54, 55, 57, 60, 62, 65, 71, 72, 81, 99

Policy effectSupplies provided same day as an E/M or procedure in these non-facility POS are not separately reimbursable because supply costs are incorporated into the E/M or procedure reimbursement.

Applicable claim formApplies to supplies reported on CMS-1500 (physician/service claims) when provided in non-facility POS listed above.