CurrentUnitedHealthcarePolicy N/A

Non‑covered and covered billing codes for Medicaid (UB‑04)

Defines UnitedHealthcare Community Plan's reimbursement stance for CPT/HCPCS codes on UB‑04 (or electronic equivalent) for Medicaid products, including state-specific covered or non‑covered code lists and attachments that govern claim adjudication.

Policy Summary

PayerUnitedHealthcare

PolicyNon‑covered and covered billing codes for Medicaid (UB‑04)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using the code(s) that correctly describe services on UB‑04 or electronic equivalent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UB‑04form(s) governed

state‑specificstate attachments

frequentattachment updates

Medicaidline of business

Coverage Criteria

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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 an individual state fee schedule, coverage is governed by the state fee schedule and plan rules; codes not on a state fee schedule will deny as not covered for that state unless negotiated or otherwise specified in benefit/contractual documents.

State list behavior

Some states utilize an explicit Covered Codes List — for those states any code not on that covered list will deny as not covered for that state.
Some states utilize an explicit Non‑Covered Codes List — any code appearing on that state's non‑covered list will deny as not covered for that state unless a benefit/contractual exception exists.

All covered services remain subject to all UnitedHealthcare Community Plan reimbursement policies and may still deny for reasons other than coverage (e.g., other policy criteria).

The Non‑Covered and Covered Codes lists and attachments are administered by Date of Service and apply to outpatient claims; inpatient applicability may vary by state (e.g., Kansas has a Non‑Covered ICD‑10‑PCS list that applies to both inpatient and outpatient claims).

State exceptions: specific states have configured behavior per attachment (examples include Arizona using a Covered Codes List with certain codes designated non‑covered for subprograms; Hawaii, Maryland, Massachusetts, Mississippi, Missouri, New Jersey and others utilize Non‑Covered Codes Lists; Arizona, Indiana, Kansas, Minnesota, Texas and others utilize Covered Codes Lists; some states are not administered by this policy).

Coding and Code Status

General coverage rule for CPT/HCPCSmixedCovered

No codes listed

State fee schedule presence

Policy ruleCodes not on a state's Medicaid fee schedule are considered not covered for that state's Medicaid market unless there are benefit and/or contractual agreements with negotiated rates.

State covered vs non-covered listsSome states maintain explicit covered-code lists; any code not on a state's covered list will deny as not covered for that state.

CMS NPFS interactionIf a CPT/HCPCS code is on a state fee schedule but not on the CMS NPFS, it will be covered for that state's Medicaid market but remains subject to other UnitedHealthcare reimbursement policies.

Claims Submission & Provider Responsibilities

Billing Rule

Submit accurate UB‑04 claims with correct CPT/CMS coding

You are responsible for submitting accurate claims using the code or codes that correctly describe the health care services provided on the UB‑04 (or electronic equivalent). UnitedHealthcare Community Plan uses CPT, CMS or other coding guidelines to determine reimbursement; coding methodology, regulatory requirements, benefit design, contracts and other factors may supplement or supersede this policy.

Submit claims on UB‑04 or electronic equivalent using the codes that accurately describe the services billed.
Follow CPT, CMS and other coding guidelines because UnitedHealthcare Community Plan uses those guidelines to determine reimbursement.
Be aware that state/federal regulations, benefit documents and provider contracts may modify how this policy is applied.

Definitions

Experimental or Investigational Services

DefinitionExperimental or Investigational Services: medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time of coverage determination, are either not approved by the U.S. Food and Drug Administration for the proposed use and not identified in the American Hospital Formulary Service or United States Pharmacopoeia Dispensing Information as appropriate, or are subject to review and approval by an institutional review board.

FDA exceptionDevices approved under the Humanitarian Use Device exemption are not considered Experimental or Investigational.

ScopeIncludes services, technologies, supplies, treatments, procedures, drug therapies, medications and devices evaluated at time of determination.

Non-covered codes / administration Q&A

Definition of non-covered codesNon-covered codes are codes for services considered non-reimbursable per state guidelines, CMS, or reimbursable by a payer other than UnitedHealthcare Community Plan.

Determination sourceUnitedHealthcare Community Plan follows state guidelines as outlined in the individual state provider manual, state website or other regulatory materials to determine non-covered codes.

Administration timingThis policy is administered based on Date of Service.

Claim setting applicabilityThe Non Covered and Covered Codes apply to outpatient claims (inpatient applicability is governed by specific state lists where noted).