CurrentUnitedHealthcarePolicy N/A

Medicaid Covered and Non-Covered CPT/HCPCS Codes Policy

Defines UnitedHealthcare Community Plan's reimbursement stance for CPT and HCPCS codes in Medicaid markets — specifying that codes not on a state's Medicaid fee schedule or the CMS Physician Fee Schedule (NPFS) are generally not covered unless state-specific lists or contractual/benefit exceptions apply. Applies to UnitedHealthcare Community Plan Medicaid products and services billed on CMS1500/UB04 as specified.

Policy Summary

PayerUnitedHealthcare

PolicyMedicaid Covered and Non-Covered CPT/HCPCS Codes Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReview the enrollee's benefit document and the applicable state Medicaid fee schedule or covered/non-covered code lists to determine if a code is covered.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All US states referencedState-specific covered/non-covered lists referenced

Category II codesNot payable across Medicaid markets (generally)

3008FPayable in some jurisdictions (examples)

Policy At-a-Glance

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.

CURRENT — Medicaid Covered and Non-Covered CPT/HCPCS Codes Policy: This policy defines UnitedHealthcare Community Plan's reimbursement stance for CPT and HCPCS codes in Medicaid markets — specifying that codes not on a state's Medicaid fee schedule or the CMS Physician Fee Schedule (NPFS) are generally not covered unless state-specific lists, contractual agreements, or member benefit exceptions apply. It applies to UnitedHealthcare Community Plan Medicaid products and covers services billed on CMS1500 (and, when specified, UB04) claim forms. The policy and any reimbursement determinations are administered based on the Date of Service.

Policy header

PayerUnitedHealthcare

PolicyMedicaid Covered and Non-Covered CPT/HCPCS Codes Policy

Policy CodeN/A

StatusCURRENT

Scope SummaryDefines UnitedHealthcare Community Plan's reimbursement stance for CPT and HCPCS codes in Medicaid markets — specifying that codes not on a state's Medicaid fee schedule or the CMS Physician Fee Schedule (NPFS) are generally not covered unless state-specific lists or contractual/benefit exceptions apply. Applies to UnitedHealthcare Community Plan Medicaid products and services billed on CMS1500/UB04 as specified.

Key ActionConsult state attachments (Covered Codes Lists and Non-Covered Codes Lists) for state- and product-specific coverage exceptions; attachments are updated frequently.

Covered and Non-Covered Codes

Category II CPT codes (xxxxF)CPTNot Covered

Category II codes (ending in F)	Identified as performance measurement codes; per CMS not payable by Medicare and UHC Community Plan determined them not payable in Medicaid markets generally
3008F	Body Mass Index documented — exceptions: payable for certain ages/States under specific criteria (e.g., payable for ages 3-17 when submitted with qualifying E/M and diagnosis in some states; payable once per year for WI/DC)
0500F	Category II code noted as covered for Tennessee Medicaid (state exception)
0503F	Category II code noted as covered for Tennessee Medicaid (state exception)

State-specific Covered Codes Lists (examples)mixedCovered

S5151	Covered for New Jersey Medicaid Family Care only (state exception)
00104	Considered Non-Covered for Arizona Developmentally Disabled (AZDDD) (state exception)
90870	Considered Non-Covered for Arizona Developmentally Disabled (AZDDD) (state exception)
T1016	Considered Non-Covered for Arizona LTC (AZLTC); HCPCs T1016 also noted covered for some Ohio product (1915i) as state exception
H0038	HCPCS code noted as covered for Ohio 1915i product
H0038HQ	HCPCS code noted as covered for Ohio 1915i product
H2023	HCPCS code noted as covered for Ohio 1915i product
H2025	HCPCS code noted as covered for Ohio 1915i product

The policy includes numerous state-specific attachments (Covered Codes Lists and Non-Covered Codes Lists) that are updated frequently; providers must consult the attachments for specifics by state and product when determining coverage. The attachments provide the authoritative state-level lists that drive coverage decisions and may differ by program, plan, or product.

Many states are listed as using either Covered Codes Lists or Non-Covered Codes Lists and therefore may have exceptions to the general rule. Examples called out in the policy include: Arizona, Colorado, Florida, Hawaii, Idaho, Indiana, Kansas, Kentucky, Maryland, Massachusetts, Michigan excluded, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania excluded, Rhode Island excluded, Tennessee, Texas, Virginia, Washington, Wisconsin, Washington DC. Providers should review the state attachments for specific code-level exceptions.

What Providers Must Do

Documentation Required

Verify coverage against state fee schedule and member benefits

Providers must review the enrollee's benefit document and the applicable state Medicaid fee schedule or covered/non-covered code lists to determine if a code is covered. When benefit definitions differ from UHC definitions, the enrollee's benefit document prevails.

Prior Authorization

Prior authorization for non-covered codes where medical necessity may apply

A code listed as non-covered on a state's fee schedule may be considered for coverage if found medically necessary through a prior authorization request per state exceptions.

Billing Rule

Submit accurate claim codes and follow CMS/AMA coding guidance

Providers are responsible for accurate claim submission. Reimbursement is based on codes that correctly describe services and follows CPT/CMS coding guidelines and state fee schedules. The policy is administered by Date of Service.

Key Terms

Definitions

Non-covered codeA procedure code that is not reimbursable per state guidelines, CMS, or reimbursable by another payer; not listed on applicable state Medicaid fee schedule or CMS NPFS for that market.

Category II codesCPT procedure codes ending in 'F' used for performance measurement; per CMS not payable by Medicare and determined by UnitedHealthcare Community Plan to be not payable in Medicaid markets generally.

Covered Codes List / Non-Covered Codes ListState-specific attachments listing codes that are explicitly covered or not covered for that state's Medicaid product(s). Some states use a covered-only list (codes not on list deny).

Date of Service administrationThis policy is applied based on the date the service was provided (Date of Service).

Context and Rationale

Category II CPT codes (procedure codes ending in 'F') are used primarily for performance measurement and, per CMS, are not payable by Medicare. UnitedHealthcare Community Plan reviewed Medicaid fee schedules and determined that Category II codes are generally not payable in its Medicaid markets; consequently, Category II codes will not be payable in UnitedHealthcare Community Plan markets unless a state-specific attachment or contract explicitly provides coverage.

State attachments are updated on an ongoing basis — the policy history shows regular, frequent updates to Covered and Non-Covered Codes Lists across many states. Providers must consult the latest attachments for the state and product in question to confirm current coverage status and any recent changes that may affect claims or prior authorization requirements.

Policy Update Changes

2026-04-19Policy version changeLatest

Attachments: Covered Codes Lists updated (Arizona); Non-Covered Codes Lists updated (Missouri, Washington); History entries prior to 2024-04-19 archived.

2026-04-12Policy version change

Attachments: Covered Codes Lists updated (Indiana); Non-Covered Codes Lists updated (Maryland, Washington); History entries prior to 2024-04-12 archived.

2026-03-29Policy version change

Attachments: Covered Codes Lists updated (Wisconsin); Non-Covered Codes Lists updated (Kentucky, Missouri, North Carolina, New York, Washington); History entries prior to 2024-03-29 archived.

2026-03-22Policy version change

Attachments: Covered Codes Lists updated (Texas); Non-Covered Codes Lists updated (Washington); History entries prior to 2024-03-22 archived.

2026-03-15Policy version change

Attachments: Covered Codes Lists updated (Ohio); Non-Covered Codes Lists updated (Colorado, Kentucky, New York, Washington); History entries prior to 2024-03-15 archived.

2026-03-08Policy version change

Attachments: Covered Codes Lists updated (Indiana, Kansas, Wisconsin); Non-Covered Codes Lists updated (Colorado, Florida, Maryland, Massachusetts, Missouri, Nebraska, New York, North Carolina); History entries prior to 2024-03-08 archived.

2026-02-22Policy version change

Attachments: Covered Codes Lists updated (Kansas, Texas); Non-Covered Codes Lists updated (Colorado, Missouri, North Carolina, New Jersey); History entries prior to 2024-02-22 archived.

2026-02-15Policy version change

Attachments: Covered Codes Lists updated (Arizona, DC Washington, Kansas); Non-Covered Codes Lists updated (Maryland, Nebraska, Washington); History entries prior to 2024-02-15 archived.

2026-02-08Policy version change

Attachments: Covered Codes Lists updated (Indiana, Ohio, Texas, Wisconsin); Non-Covered Codes Lists updated (Florida, New Jersey, New York, Washington, Virginia); History entries prior to 2024-02-08 archived.

2026-01-28Policy version change

Attachments: Covered Codes Lists updated (Arizona); History entries prior to 2024-01-28 archived.

2026-01-25Policy version change

Attachments: Covered Codes Lists updated (Arizona, Indiana, Kansas); Non-Covered Codes Lists updated (California Removed, Maryland, Washington); History entries prior to 2024-01-25 archived.

2026-01-18Policy version change

Attachments: Covered Codes Lists updated (Indiana, Texas); Non-Covered Codes Lists updated (Washington); History entries prior to 2024-01-18 archived.

2026-01-11Policy version change

Attachments: Covered Codes Lists updated (Indiana, Idaho, Wisconsin); Non-Covered Codes Lists updated (Kentucky, Nebraska, New York); History entries prior to 2024-01-11 archived.

2026-01-01Policy version change

Attachments: Covered Codes Lists updated (Indiana, Texas, Wisconsin); Non-Covered Codes Lists updated (Colorado, Maryland, Nebraska, Washington); History entries prior to 2024-01-01 archived.

2025-12-28Policy update

State exceptions updated.

2025-12-14Policy version change

Attachments: Covered Codes Lists updated (Indiana, Texas); Non-Covered Codes Lists updated (Hawaii, New Jersey, North Carolina, Washington); History entries prior to 2023-12-14 archived.

2025-12-07Policy version change

Attachments: Covered Codes Lists updated (Arizona, DC Washington, Kansas, New Mexico, Wisconsin); Non-Covered Codes Lists updated (Colorado, Maryland, Missouri, Virginia, Washington); History entries prior to 2023-12-07 archived.

2025-11-23Policy version change

Attachments: Covered Codes Lists updated (Kansas, Ohio); Non-Covered Codes Lists updated (Washington, Nebraska); History entries prior to 2023-11-23 archived.

2025-11-16Policy version change

Attachments: Covered Codes Lists updated (Arizona, Indiana, Texas); Non-Covered Codes Lists updated (Massachusetts, New York); History entries prior to 2023-11-16 archived.

2025-11-09Policy version change

Attachments: Covered Codes Lists updated (Arizona, DC Washington, Texas); Non-Covered Codes Lists updated (Florida, Missouri, Virginia); History entries prior to 2023-11-09 archived.

2025-10-26Policy version change

Attachments: Covered Codes Lists updated (Arizona, Missouri); History entries prior to 2023-10-26 archived.

2025-10-19Policy version change

Attachments: Covered Codes Lists updated (Indiana, Wisconsin); History entries prior to 2023-10-19 archived.

2025-10-12Policy version change

Attachments: Non-Covered Codes Lists updated (Nebraska, Missouri); History entries prior to 2023-10-12 archived.

2025-10-05Policy version change

Attachments: Covered Codes Lists updated (Arizona, DC Washington, Indiana, New Mexico, Wisconsin); Non-Covered Codes Lists updated (Maryland, Kentucky, Washington); History entries prior to 2023-10-05 archived.

See the document-level 'Policy Update Changes' (History) section for detailed revision history and timeline entries; that section contains the policy version changes and attachment update history.

Policy Summary

PayerUnitedHealthcare

PolicyMedicaid Covered and Non-Covered CPT/HCPCS Codes Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReview the enrollee's benefit document and the applicable state Medicaid fee schedule or covered/non-covered code lists to determine if a code is covered.

SourceLink

On This Page

Medicaid Covered and Non-Covered CPT/HCPCS Codes Policy

Policy At-a-Glance

Covered and Non-Covered Codes

What Providers Must Do

Key Terms

Context and Rationale

Other Policies to Review

Policy Update Changes