CurrentUnitedHealthcarePolicy N/A

Reimbursement policy: CPT and HCPCS code coverage for UnitedHealthcare Community Plan Medicaid markets

Defines UnitedHealthcare Community Plan's reimbursement stance for CPT and HCPCS codes in Medicaid markets, including state-specific covered/non-covered code lists and exceptions; applies to services billed on CMS1500/UB04 as specified and affects network and non-network providers submitting claims for UnitedHealthcare Community Plan Medicaid products.

Policy Summary

PayerUnitedHealthcare

PolicyCPT/HCPCS code coverage in UnitedHealthcare Community Plan Medicaid markets (covered and non-covered code lists, state exceptions)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a prior authorization request when a non-covered code for a covered service is medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

not payableCategory II codes status

CMS1500Form applicability

state-specificState lists

1State exceptions noted

Coverage Rules and Attachments

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.

Coverage rules for CPT/HCPCS codes in Medicaid markets

General coverage stance based on code presence on state fee schedule and CMS NPFS.

UnitedHealthcare Community Plan considers any CPT and HCPCS codes that are not on a state Medicaid fee schedule as not covered for that state's Medicaid market unless there are benefit and/or contractual agreements with negotiated rates.

If a CPT and/or HCPCS code is on the CMS National Physician Fee Schedule (NPFS) but not on a state's Medicaid fee schedule, coverage is determined by the state fee schedule; codes not on the state fee schedule are treated as not covered for that state unless a benefit or contractual agreement provides coverage.

Any CPT and/or HCPCS codes that are not on the CMS NPFS but are on the state fee schedule will be covered for that state's Medicaid market, but remain subject to all UnitedHealthcare Community Plan reimbursement policies and may deny under other policies.

Any CPT and/or HCPCS codes that are on neither the CMS NPFS nor an individual state fee schedule will deny as not covered in that particular state unless there are benefit and/or contractual agreements with negotiated rates; such codes will be placed on the UnitedHealthcare Community Plan NonCovered Codes List.

Some Medicaid markets use a covered-codes list approach; for those states, any code not on the state's covered code list will deny as not covered for that product/program.

Category II CPT codes (codes ending with the suffix 'F') are not payable across UnitedHealthcare Community Plan Medicaid markets except where a specific state or program exception permits payment.

Providers are responsible for accurate claim submission and must reference enrollee benefit documents and provider manuals; benefit document definitions prevail where they differ from this policy.

Attachment update history

Attachment updates and history archival notes (selected examples):

Selected attachment and history entries

1/11/2026: Policy Version Change — Attachments: Covered Codes Lists updated Indiana, Idaho and Wisconsin; Non-Covered Codes Lists updated Kentucky, Nebraska and New York.
12/28/2025: Policy Version Change — State Exceptions updated; Attachments: Covered Codes Lists updated Indiana and Texas; Non-Covered Codes Lists updated Hawaii, New Jersey, North Carolina and Washington.
8/10/2025: Policy Version Change — Attachments: Covered Codes Lists updated Indiana, Kansas, Ohio, and Washington DC and Wisconsin; Non-Covered Codes Lists updated Colorado and Washington.
5/25/2025: Policy Version Change — Attachments: Covered Codes Lists updated Indiana and Texas; Non-Covered Codes Lists updated Kentucky, New York, and Virginia.

State Exceptions

State exception added:

North Carolina was added to the State Exceptions section (entry dated 4/10/2024).

State Exceptions and state-specific policy exceptions are updated in the Resources/History entries; review state-specific attachments for details on any exceptions that modify coverage for particular codes or programs.

Prior Authorization, Attachments, and State Exceptions — Provider Impacts

Prior Authorization

Attachments updates - Covered/Non-Covered Codes Lists

Attachments Section: Covered Codes Lists and Non-Covered Codes Lists are maintained and updated regularly. Providers should reference the state-specific Covered Codes Lists and Non-Covered Codes Lists in the Attachments section to determine billing and coverage status for procedure codes. When a code is listed as non-covered for a covered service in a state-specific list, that code may still be eligible for coverage if medical necessity is demonstrated through a prior authorization request. Providers should review the latest Attachments updates for changes to Covered and Non-Covered Codes by state before submitting claims or prior authorization requests.

Providers must consult the Attachments section for the most recent Covered Codes List for the member's state before billing.
If a procedure code appears on a state's Non-Covered Codes List but is clinically necessary, submit a prior authorization request with supporting medical necessity documentation; a non-covered code for a covered service may be approved.
State exceptions exist — several states utilize Covered Codes Lists (e.g., Indiana, Texas, Ohio, Kansas, Minnesota, Wisconsin, Idaho, Arizona, Washington DC) while others utilize Non-Covered Codes Lists (e.g., North Carolina, Washington, Colorado, New York, Virginia).
Ohio-specific guidance: A code not listed on an Ohio Department of Medicaid fee schedule is not automatically denied; UnitedHealthcare will consider prior authorization for non-listed codes. Certain HCPCS (e.g., H0038, H0038HQ, H2023, H2025, T1016) are covered for specified Ohio products.
Tennessee: Category II codes 0500F and 0503F are covered for Tennessee Medicaid.
Washington DC and Wisconsin: Covered Codes Lists apply; example — Category II code 3008F (BMI documented) payable once per member per year per provider with appropriate diagnosis.

Terminology and Attachment Notes

CPT Category II Procedure Codes

IdentificationCPT Category II procedure codes are identified by codes ending with the suffix 'F' (format xxxxF)

PurposeUsed primarily for performance measurement

Payer stanceNot payable in UnitedHealthcare Community Plan Medicaid markets (Category II codes considered not covered)

Medicare guidancePer CMS, Category II codes are not payable by Medicare

Experimental or Investigational Services

DefinitionServices, 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 (IRB) oversight

FDA statusNot approved by the U.S. Food and Drug Administration for the proposed use and not identified in AHFS or USP Dispensing Information for that use

IRB oversightSubject to review and approval by any institutional review board for the proposed use (FDA Humanitarian Use Device exemption excluded)

Attachments Section

Purpose of attachmentsLists of covered and non‑covered procedure/code entries by state appended to the policy

Content updatesAttachments Section has been updated repeatedly with Covered Codes Lists and Non‑Covered Codes Lists for multiple states (examples include Arizona, Indiana, Texas, Wisconsin, Colorado, Maryland, Nebraska, Washington, New York)

Reference for providersProviders must consult the state‑specific attachments to determine coverage for a given code in that state's Medicaid market

State Exceptions

DefinitionState Exceptions are state‑specific deviations or additions to the general policy (examples shown in the policy history)

ExampleNorth Carolina was added to the State Exceptions section (entry dated 4/10/2024)

MaintenanceState Exceptions and attachments are updated via policy version changes and archived history entries as noted in the Resources/History sections

OpenPayer

Reimbursement policy: CPT and HCPCS code coverage for UnitedHealthcare Community Plan Medicaid markets

Coverage Rules and Attachments

CPT/HCPCS Code Lists and Coding Notes

Prior Authorization, Attachments, and State Exceptions — Provider Impacts

Terminology and Attachment Notes

xxxxF	CPT Category II codes (suffix F)
3008F	Category II code for BMI documented (example; referenced in policy)