CurrentUnitedHealthcarePolicy 2026R0104A

Reimbursement for Contrast and Radiopharmaceutical Materials (CMS 1500)

Defines UnitedHealthcare's reimbursement rules for High and Low Osmolar Contrast Materials (HOCM/LOCM) and radiopharmaceutical materials when billed on the CMS-1500 form (or electronic equivalent) for Commercial and Individual Exchange plans (excludes Oxford). Applies to network and non-network physicians and other qualified health care professionals.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement for Contrast and Radiopharmaceutical Materials (CMS 1500)

Policy CodePolicy 2026R0104A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDo not separately bill or expect reimbursement for contrast or radiopharmaceutical materials when the imaging procedure is performed in a facility Place of Service; separate reimbursement allowed in non‑facility settings and in ASC (POS 24) for eligible procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form(s) governed

Commercial & Exchangeplans covered

POS 24ASC exception

up to 2 daysprior authorization window

A4641, J1245...

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Contrast and Radiopharmaceutical Reimbursement Criteria

Contrast and Radiopharmaceutical Materials reimbursement criteria

Rules for when separate reimbursement is allowed or denied.

Services Reported in a CMS Facility Place of Service: Do not reimburse separate technical component or contrast/radiopharmaceutical materials to physicians or other qualified health care professionals when the imaging or therapeutic procedure is performed in a facility Place of Service (examples: POS 19, 21, 22, 23, 24, 26, 34, 51, 52, 56, or 61).

ASC exception: Separate reimbursement allowed in Ambulatory Surgical Center (POS 24) when provided in conjunction with eligible imaging procedures that are not included on the CMS Ambulatory Surgical Center Fee Schedule (ASCFS) Addendum BB (procedures listed on ASCFS Addendum BB have materials included in the facility case rate and are not separately reimbursable).

Service Reported in a CMS Non-Facility Place of Service: When the imaging or therapeutic nuclear medicine procedure is performed in a non-facility setting, separate reimbursement is allowed to the Same Group Physician or Other Qualified Health Care Professional for HOCM, LOCM or Radiopharmaceutical Materials when reported on the same date of service with a procedure code that requires contrast or radiopharmaceutical materials.

Timing: Separate reimbursement is allowed for contrast and radiopharmaceutical materials reported with a date of service up to two days prior to a nuclear medicine imaging scan (CPT codes 78012-79999).

CMS bundling guidance: Do not separately reimburse HCPCS A9512 when submitted with A9538 or A9560 on the same day by the Same Group Physician or Other Qualified Health Care Professional.

Eligibility dependency: Contrast and radiopharmaceutical materials are only separately reimbursable when the associated imaging or therapeutic procedure is itself eligible for reimbursement (materials reported with procedures denied under another UnitedHealthcare reimbursement policy are not separately reimbursable).

Reference: See UnitedHealthcare code lists (Contrast-and-Radiopharm-Materials-Code-List, Nuclear-Medicine-Procedure-Code-List, Eligible Imaging and Therapeutic Procedures Code List, ASCFS-Eligible-Imaging-and-Therapeutic-Proc-Code-List) for specific codes required or eligible.

Example Codes and Timing Rules

Contrast and Radiopharmaceutical Materials (examples)HCPCS

A4641	Contrast and radiopharmaceutical materials (example code referenced in ASCFS mapping)
A4642	Contrast and radiopharmaceutical materials (example code referenced)
A9512	Radiopharmaceutical material (not separately reimbursed with A9538 or A9560 same day)
J1245	Radiopharmaceutical or contrast product (referenced)
Q3001	Radiopharmaceutical material (referenced)

Prior-date window for contrast/radiopharmaceutical materials

Allowed prior-date windowSeparate reimbursement allowed for contrast and radiopharmaceutical materials reported with a date of service up to two days prior to a nuclear medicine imaging scan (CPT 78012-79999).

ScopeThis two-day prior allowance applies only to nuclear medicine imaging scans (CPT 78012-79999).

LimitationNot applicable to non-nuclear imaging procedures — the two-day prior rule does not extend to other eligible imaging or therapeutic procedures.

Billing, Prior Authorization, and Provider Guidance

Billing Rule

Prior authorization / billing risk notes — facility vs non‑facility rules

Do not separately bill or expect reimbursement for contrast (HOCM/LOCM) or radiopharmaceutical materials when the imaging or therapeutic procedure is performed in a facility Place of Service; these materials are considered part of the technical component or facility case rate. Separate reimbursement is allowed in Ambulatory Surgical Center (POS 24) only when provided with eligible imaging procedures not listed on the CMS ASCFS Addendum BB. When services are performed in a non-facility setting, separate reimbursement is allowed to the Same Group physician or other qualified health care professional when reported the same date as the procedure, and may be allowed up to two days prior to a nuclear medicine imaging scan. Additionally, do not separately reimburse HCPCS A9512 when submitted with A9538 or A9560 on the same day by the Same Group provider.

Facility POS (examples: 19, 21, 22, 23, 24, 26, 34, 51, 52, 56, 61): no reimbursement to physician for technical component/global service or for HOCM/LOCM/radiopharmaceutical materials when billed with facility POS.
ASC (POS 24): separate reimbursement allowed only for eligible imaging procedures not included on CMS ASCFS Addendum BB; procedures listed on ASCFS Addendum BB include materials in the facility case rate and are not separately reimbursable.
Non-facility POS: separate reimbursement allowed to Same Group physician/other qualified professional when reported same date as the procedure that requires contrast/radiopharmaceutical materials.

Key Terms

Same Group Physician or Other Qualified Health Care Professional

DefinitionAll physicians and/or other qualified health care professionals of the same group reporting the same Federal Tax Identification number.

Applies toDetermines when a Same Group provider may receive separate reimbursement for contrast or radiopharmaceutical materials when reported on the same date of service or per timing rules.

Example implicationDo not separately reimburse A9512 when submitted with A9538 or A9560 on the same day by the Same Group provider, per CMS guidelines referenced in the policy.

Osmolar Contrast Materials

DefinitionAn iodine-based substance, administered intravascularly, intra-articularly or intrathecally, used to enhance the visibility of structures or fluids within the body during imaging or interventional procedures (e.g., X-ray, MRI, CT, or cardiovascular procedures).