ModifiedUnitedHealthcarePolicy 2025R7111F

Reimbursement policy — Incontinence supplies (CMS-1500)

Defines UnitedHealthcare Community Plan reimbursement rules, coding and monthly quantity limits for disposable incontinence supplies billed on CMS-1500 forms for Medicaid products and applicable states.

Policy Summary

PayerUnitedHealthcare

PolicyIncontinence supplies reimbursement (CMS-1500)

Policy CodePolicy 2025R7111F

Change TypeState-specific updates (WA addedCA removedVA, ID updates)

Effective Date

Next Review Date

Key ActionWhen billing, include both a valid incontinence diagnosis and the diagnosis for the condition causing the incontinence to avoid denials.

SourceLink

POLICY UPDATE CHANGES

State Exceptions Section: Washington added and California removed.

Policy Version Change: State Exception Section: Virginia updated.

Incontinence Supplies State Specific Age Requirements Section: Idaho Added; Group 1 and Group 2 HCPCS Codes State Maximums Table: ID added.

300/moGroup1 default max

300/moGroup2 default max

9-10/dayDaily equivalent

>1 ICD-10Claim requirement

300/mo

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.

multipleHistory updates

Coverage and Medical Necessity Criteria

Diagnosis coding requirements

Claims must include both an incontinence diagnosis and the diagnosis for the condition causing the incontinence; symptom-only codes are insufficient.

Required diagnoses

An ICD-10 diagnosis code from the Incontinence Supplies ICD-10 Diagnosis Codes List must be present on the claim.
An ICD-10 diagnosis code reflecting the condition causing the incontinence must also be present on the claim.
If one or more codes from the Incontinence Supplies ICD-10 Diagnosis Codes List are the ONLY diagnosis code(s) on the claim, all incontinence supplies will be denied.

Quantity and state-specific rules

Quantity limits default to 300 units per month for Group 1 and Group 2 supplies unless a state-specific maximum or exception applies.

Group 1 default limit: Group 1 default maximum: 300 individual units/items per member per month (equivalent to ~9–10 items per day); all Group 1 codes are monthly aggregates and the maximum amount of each size per member per month is not allowed.

Group 2 default limit: Group 2 default maximum: 300 individual units/items per member per month; Group 2 supplies are allowed only if the member requires Group 1 supplies.

State-specific maximums and examples

State examples for Group 1 monthly maxima: 180/month (VA; certain AZ LTC), 186/month (KS, MS), 192/month (KY), 200/month (NJ, NM, TN, WA), 210/month (DC), 240/month (AZ LTC <21, ID, TX), 250/month (MA, MD), 300/month (MN, NC, NE, OH, PA, RI, WI).
State examples for Group 2 monthly maxima: 100/month (MN), 120/month (TX), 150/month (ID, NM, RI), 180/month (VA; certain AZ LTC), 186/month (KS, MS), 200/month (NJ, TN, WA), 210/month (DC), 300/month (NC, NE, OH, PA, WI).

Vendor shipment and stockpiling rules

Vendors must confirm member supplies on hand before each shipment and may not allow stockpiling.

Vendor contact requirement: Vendors must not schedule automatic shipments; prior to each shipment the vendor should contact the member or caregiver to determine quantity on hand, appropriate size and shipment date.

Shipment timing and maximum days supplied: The delivery date must not be prior to the member having 15 days of supplies available; an order must not contain more than 30 days' worth of supplies; delivering items where standard packaging exceeds 45 days or more supply is not permitted.

Stockpiling prohibition: Stockpiling of supplies is not allowed; vendors should confirm supplies on hand before shipment and avoid sending excess quantities.

Incontinence supplies coverage criteria

Coverage of incontinence supplies is subject to diagnosis, linkage between groups, per-code and per-state limits.

Diagnosis requirement: Claims must include a valid incontinence diagnosis AND a diagnosis for the condition causing the incontinence; symptom-only codes will not be paid.

Group 2 coverage linkage: Group 2 supplies are reimbursed only when the member also receives Group 1 supplies and their primary use is to maintain sanitary conditions related to Group 1 needs; if the member does not require Group 1 supplies, Group 2 supplies will not be reimbursable (subject to state exceptions).

ANY of the following

A4554 limit: Code A4554 is limited to 300 units per month.
Washington state exceptions:

HCPCS Codes and State Maximums

Provider Requirements and Billing Instructions

Prior Authorization

Prior Authorization Where State Maximums Apply

Authorization may be required when state-specific monthly maximums are exceeded or per the provider manual/benefit. Check state maximums before billing; if the member’s requested quantity exceeds the state limit, obtain prior authorization as required by the member’s benefit.

State maximums vary by HCPCS Group and state — see State Maximums and State Exceptions.
Prior authorization requirements may be found in the provider manual or member benefit; obtain authorization when limits are exceeded.

Documentation Required

Documentation and Vendor Shipment Rules

Documentation of medical necessity is required to support requests to exceed monthly maximums. Vendors must not auto-ship supplies; they must confirm quantity on hand, appropriate size, and ship only when member has ≤15 days supply. Orders should not exceed 30 days' worth and standard packaging that results in >45 days supply is not permitted.

Definitions of Supply Groups

inv-14: Disposable diapers, briefs, protective underwear, pull-ons, liners (disposable) — Group 1 definition

Definition (Group 1)Disposable diapers, briefs, protective underwear, pull-ons, liners (disposable).

Primary useProducts intended to manage member personal continence needs (required for reimbursement of related Group 2 supplies).

ExclusionsWashable (non-disposable) items are not addressed by this policy.

inv-15: Disposable underpads (commonly called chux) — Group 2 definition

Definition (Group 2)Disposable underpads (commonly called chux).

Coverage linkageGroup 2 supplies are covered only when the member also receives Group 1 supplies; primary use must be to maintain sanitary conditions related to Group 1 needs.

Policy Summary

PayerUnitedHealthcare

PolicyIncontinence supplies reimbursement (CMS-1500)

Policy CodePolicy 2025R7111F

Change TypeState-specific updates (WA addedCA removedVA, ID updates)

Effective Date

Next Review Date

Key ActionWhen billing, include both a valid incontinence diagnosis and the diagnosis for the condition causing the incontinence to avoid denials.

SourceLink

On This Page

North Carolina per-code limits (examples): T4521-T4524, T4529-T4530, T4533, T4543 = 192/month; T4525-T4528, T4531-T4532, T4534, T4544 = 200/month; A4554 = 150/month.

State exceptions: Some states apply special rules or exceptions (examples: Mississippi per state regulation exclusions; New Mexico limits to either Group 1 or Group 2 per month; New York exempt; Virginia allows Group 2 when no Group 1 is required and permits 90-day supply for certain codes).

Washington allows T4536, T4537, T4538, T4539, T4541, T4543, and T4544 per WAHLOP-WAIMCRE Reentry Program.

North Carolina state exceptions: North Carolina applies per-code monthly limits and excludes some Group 2 denials when no Group 1 supplies are received (see state-specific table).

Submit documentation showing medical necessity when exceeding Group 1 monthly maximums.
Vendors must contact member/caregiver before each shipment and may not schedule automatic recurring shipments.
Do not deliver quantities that create stockpiling (orders >30 days' worth or standard packaging >45 days).

Billing Rule

Billing Requirement for Diagnosis Codes

Claims must include both a valid incontinence diagnosis (symptom) and a diagnosis code for the underlying condition causing the incontinence. Claims listing only symptom codes or symptoms alone will not be paid.

Include an incontinence symptom diagnosis code (e.g., urinary incontinence) AND a causative condition diagnosis code on the claim.
Claims billed with symptom codes only are at risk of denial.

Denial Risk

Coverage Linkage Between Group 1 and Group 2 Supplies

Group 2 supplies are reimbursed only when the member also receives Group 1 supplies. Group 2 items are intended to maintain sanitary conditions in conjunction with Group 1; they are not reimbursable if Group 1 supplies are not needed. When reimbursing Group 2, adhere to any state-specific maximums.

If member does not require Group 1 supplies, Group 2 supplies will not be reimbursed.
Group 2 maximums may differ by state — check State Maximums and obtain authorization if limits are exceeded.

State limitsGroup 2 monthly maximums vary by state (examples: MN=100, TX=120, ID/NM/RI=150, NC/NE/OH/PA/WI=300).

inv-16: Group 2 supplies — additional Group 2 detail

Default quantity limit (Group 2)Default is 300 units per member per month unless a state-specific maximum applies.

State-specific examplesMN=100/month; TX=120/month; ID/NM/RI=150/month; VA/AZ LTC (21+) =180/month; KS/MS=186/month; NJ/TN/WA=200/month; NC/NE/OH/PA/WI=300/month.

Coverage conditionGroup 2 supplies are reimbursed only when the member also receives Group 1 supplies; some states exclude Group 2 denials if no Group 1 supplies are received (e.g., MS, PA, NC per state regulation).

inv-17: Group 1 supplies — additional Group 1 detail

Default quantity limit (Group 1)Default is 300 individual units per member per month (equates to ~9–10 items per day).

State-specific examplesVA/AZ LTC (21+)=180/month; KS/MS=186/month; KY=192/month; NJ/NM/TN/WA=200/month; AZ LTC under‑21/ID/TX=240/month; MA/MD=250/month; MN/NC/NE/OH/PA/RI/WI=300/month.

Aggregation ruleAll Group 1 codes are monthly aggregates; maximum units per size are not allowed; documentation required to exceed limits.

Billing requirementClaims must include a valid incontinence diagnosis plus the diagnosis for the condition causing the incontinence; symptom-only codes will not be paid.