CurrentUnitedHealthcarePolicy 2025R9O31B

UnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500

Defines UnitedHealthcare Medicare Advantage reimbursement methodology and billing rules for services submitted on the CMS-1500 form, including PC/TC splits, place-of-service effects, duplicate/repeat services, and modifier use; applies to network physicians and other qualified health care professionals serving UnitedHealthcare Medicare Advantage enrollees.

Policy Summary

PayerUnitedHealthcare

PolicyUnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500

Policy CodePolicy 2025R9O31B

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionVerify individual enrollee benefits via customer service on the member ID card.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

0-9PC/TC indicators

QuarterlyPC/TC split updates

≥20Duplicate modifiers

POS 21/24Key POS

Billing and Reimbursement Criteria

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PC/TC, POS and duplicate services billing criteria

Reimbursement and non-reimbursement rules based on PC/TC indicators and place of service:

UnitedHealthcare follows CMS NPFS guidance and uses CMS PC/TC indicators to determine eligibility for separate Professional Component (PC) and Technical Component (TC) reimbursement.

Facility place of service (POS 21): when services are subject to the PC/TC concept or have both PC and TC per CMS indicators, UnitedHealthcare will reimburse the interpreting physician or other qualified health care professional only the Professional Component; the facility is reimbursed for the Technical Component.POS 21

Code Guidance and Place-of-Service Rules

PC/TC Indicator Categories (CMS PCITC)mixed

0	Physician Service Codes
1	Diagnostic Tests (global may be carrier-priced)
2	Professional Component Only
3	Technical Component Only
4	Global Test Only
5
7	Interpretation Codes
8
9	Not Applicable

Drug Administration Codes — Not Reimbursed in POS 24CPTNot Covered

96360-96379	Therapeutic, prophylactic, and diagnostic injections and infusions — not separately reimbursed when provided in facility POS 24 per CMS NCCI guidance.
96401-96425	Chemotherapy administration codes — not separately reimbursed when provided in facility POS 24 per CMS NCCI guidance.
96521-96523	Intravenous infusion/evaluation codes — not separately reimbursed when provided in facility POS 24 per CMS NCCI guidance.

PC/TC split variance — UnitedHealthcare splits differ no more than 2.5% from CMS RBRVS

UnitedHealthcare split varianceUnitedHealthcare Medicare Advantage percentage splits are developed from the CMS Non‑Facility Total RBRVS and are updated quarterly; UnitedHealthcare splits differ no more than 2.5% from CMS NPFS RBRVS splits for each CPT/HCPCS code.

Provider Responsibilities and Prior Authorization

Prior Authorization

Provider Responsibilities and Prior Authorization

UnitedHealthcare Medicare Advantage may modify this reimbursement policy at any time to comply with changes in CMS policy and other national standard coding guidelines by publishing a new version of the reimbursement policy on this website. Providers should keep current with CMS policy changes and billing requirements by referring to the CMS or local carrier website regularly and may sign up for CMS distributions for policy or regulatory changes. UnitedHealthcare's Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements. For information on a specific enrollee's benefit coverage, verify individual enrollee benefits by calling the customer service number on the back of the member's ID card.

Applicability: This reimbursement policy applies to all Medicare Advantage products and to services reported using the CMS-1500 (or its electronic successor) and applies to all network physicians and other qualified health care professionals.
Provider responsibility: Keep current with CMS and local carrier policy updates and billing requirements; sign up for CMS distributions as needed.
Prior authorization note: UnitedHealthcare Medicare Advantage reimbursement policies do not include prior authorization notations — always verify prior authorization requirements with the member's plan via the customer service number on the member ID card.

Key Definitions

Professional Component (PC)

DefinitionProfessional Component (PC) represents the professional services (supervision and interpretation) of a CPT/HCPCS code and is reported with modifier 26.

Relation to global serviceThe PC combined with the Technical Component (TC) constitute the Global Service for CPT/HCPCS codes assigned a CMS PC/TC indicator.

Eligibility sourceUnitedHealthcare uses CMS PCITC indicators from the NPFS to determine whether a code is eligible for separate PC reimbursement.

Reporting guidanceWhen submitted in facility POS, certain PC/TC indicator categories (e.g., indicator 1 when reported globally) affect whether PC or TC will be reimbursed — see POS rules in policy.

Technical Component (TC)

DefinitionTechnical Component (TC) represents the technical portion of a CPT/HCPCS service (equipment, supplies, technical personnel) and is reported with modifier TC.

Relation to global serviceThe TC combined with the Professional Component (PC) constitute the Global Service for CPT/HCPCS codes assigned a CMS PC/TC indicator.

Eligibility sourceUnitedHealthcare follows CMS PCITC indicators in the NPFS to determine TC eligibility for separate reimbursement.

Facility POS handlingIn facility place of service, reimbursement for TC may be made to the facility rather than the physician; providers should follow the policy POS guidance.

Duplicate or Repeat Services

DefinitionDuplicate or Repeat Services are identical CPT/HCPCS codes assigned PCITC indicators 1,2,3,4,6 or 8 submitted for the same patient on the same date of service by the same provider (separate lines or claims).

PC/TC separate reportingWhen the same provider reports both PC (modifier 26) and TC (modifier TC) for the same service/date, UnitedHealthcare will consider both services eligible for reimbursement unless other policy provisions prohibit payment.

Modifier exceptionsSeparate consideration for duplicate/repeat submissions is given when appropriate modifiers (e.g., 59, 76, 77, 91, XE, XP, XS, XU and others listed) are appended to distinguish services.

Review processSubmissions of modifier 26 and TC are reviewed to identify duplicate or repeat services; generally only the first claim is reimbursed unless modifiers justify separate payment.