CurrentUnitedHealthcarePolicy N/A

Medicaid non-covered and covered CPT/HCPCS codes (UB-04 billing)

Defines UnitedHealthcare Community Plan's reimbursement stance for CPT and HCPCS codes billed on UB-04 forms for Medicaid products, including state-specific covered and non-covered code lists and attachments that govern claim denials or coverage.

Policy Summary

PayerUnitedHealthcare

PolicyMedicaid non-covered and covered CPT/HCPCS codes (UB-04 billing)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate UB-04 claims using the code(s) that correctly describe services; policy is applied based on Date of Service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UB-04claim form scope

Community Plan Medicaidline of business

state-specificstate lists

2024-2026revision history

Coverage Determination Rules

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Coverage determination rules

ONE of the following describes coverage status

If a CPT/HCPCS code is on the state Medicaid fee schedule it is covered for that state's Medicaid market (subject to other UnitedHealthcare reimbursement policies).on state fee schedule
May still deny under other UHC reimbursement policies.
Codes on the CMS National Physician Fee Schedule (NPFS) are treated as covered where applicable; codes not on CMS NPFS are considered not covered unless they appear on an individual state fee schedule or are covered via a benefit or contractual agreement with negotiated rates.on CMS NPFS or state fee schedule/contractual agreement

Any CPT/HCPCS code that is not on the CMS NPFS and not on an individual state fee schedule will be denied as not covered for that state unless there are benefit and/or contractual agreements with negotiated rates.

Some states maintain a covered-code list rather than a non-covered list; in those states any code not on the covered list will deny as not covered. Conversely, other states maintain non-covered lists that explicitly identify codes that will deny.

Covered and non-covered code lists described in state-specific attachments apply to outpatient claims as indicated by state; specific state exceptions and examples are listed in attachments (for example: Arizona, Kansas, Tennessee, Texas, Wisconsin, etc.).

If an enrollee's benefit document defines terms (for example, Experimental/Investigational Services) differently, the enrollee's benefit definition prevails.

Policy administration and claim determination are applied based on the Date of Service submitted on the claim.

Covered and Non-covered Codes (State-specific)

Coverage by code-list presencemixedNot Covered

Any CPT/HCPCS not on state fee schedule	Not covered for that state's Medicaid market unless negotiated rates exist
Any CPT/HCPCS not on CMS NPFS nor state fee schedule	Denies as not covered unless contractual/benefit agreements exist

State covered code listsmixedCovered

No codes listed

State non-covered code listsmixedNot Covered

No codes listed

CMS NPFS membership

RuleCodes not on the CMS National Physician Fee Schedule (NPFS) are considered not covered unless the code appears on the applicable state Medicaid fee schedule or there is a negotiated/contractual agreement that provides coverage.

State exceptionIf a CPT/HCPCS code is on a state Medicaid fee schedule, it is treated as covered for that state's Medicaid market unless another UnitedHealthcare reimbursement policy specifically denies it.

Contractual overrideNegotiated rates or benefit/contractual agreements can override the default non‑covered status for codes not on CMS NPFS.

Claim Submission and Coverage Enforcement

Billing Rule

Submit accurate UB-04 claims (or electronic equivalent)

You are responsible for submitting accurate claims using the UB-04 form (or electronic equivalent). This policy governs reimbursement for services billed on UB-04 forms and uses CPT, CMS and other coding guidelines for definitional purposes only; references do not guarantee reimbursement. Ensure claims reflect the code(s) that correctly describe services provided and follow applicable coding methodology, regulatory requirements, facility/provider contracts and the enrollee's benefit coverage documents.

Submit claims on the UB-04 or electronic equivalent.
Use the CPT/CMS coding guidance and state-specific fee schedules when selecting codes.
Claims must be accurate and complete to ensure appropriate reimbursement.
Policy is administered based on Date of Service.

Denial Risk

Coverage enforcement and denial risk

Codes absent from both the CMS National Physician Fee Schedule (NPFS) and the individual state fee schedule will deny as not covered in that state unless there are specific benefit or contractual agreements with negotiated rates. If a code is missing from the CMS NPFS but appears on a state fee schedule, it will be covered for that state's Medicaid market but remains subject to other UnitedHealthcare Community Plan reimbursement policies and denial conditions. Some Medicaid markets instead publish a covered-code list; in those states any code not on the covered list will deny as not covered. Note: this policy applies to outpatient claims; coverage lists may vary by state.

Codes not on CMS NPFS but present on a state fee schedule = covered in that state (still subject to other policies).
Codes not on CMS NPFS nor on the state fee schedule = deny as not covered unless negotiated/contracted rates exist.
States that use covered-code lists: any code not on the list will deny as not covered.
Non-covered/covered code determinations follow individual state provider manuals, state websites, or other regulatory materials.

Key Definitions

Experimental/Investigational Services

DefinitionServices, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time coverage is determined, are 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.

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

Policy impactIf a service is determined to be Experimental/Investigational for a particular case, the enrollee's benefit document definition of Experimental/Investigational prevails when different.

Non-covered codes

DefinitionNon‑covered codes are codes for services that are considered non‑reimbursable per state guidelines, CMS, or are 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.

ApplicationNon‑covered and covered code lists apply to outpatient claims; administration is based on Date of Service.