CurrentUnitedHealthcarePolicy N/A

Modifier usage and reimbursement guidance

Governs how CPT and HCPCS modifiers are addressed for UnitedHealthcare Community Plan Medicaid claims billed on CMS-1500 (and electronic equivalents), guiding correct coding and reimbursement for providers.

Policy Summary

PayerUnitedHealthcare

PolicyModifier usage and reimbursement guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionWhen submitting services on a CMS-1500 form with an SG modifier, report them as facility claims; they will not be processed under professional reimbursement policies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1500claim form type covered

State-specificapplies to

Comprehensivemodifier reference

Reimbursement Gridattachment

Coverage and Billing Rules for Modifiers

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.

Providers must submit accurate claims using the code(s) and modifier(s) that correctly describe services and follow CPT/CMS and UnitedHealthcare modifier guidance.

Refer to the Modifier Reimbursement Grid attachment for UnitedHealthcare Community Plan Medicaid-specific reimbursement percentages.

This document is a reference tool; for specific procedure-to-modifier guidance, refer to the Procedure to Modifier Policy and the specific reimbursement policy applicable to the procedure or modifier.

Claims reported on a CMS-1500 form with the SG modifier are treated as facility claims and are not subject to UnitedHealthcare Community Plan professional reimbursement policies for CMS-1500 submissions.

Selected Modifiers and Referenced Policies

Selected modifiers with referenced policiesmixed

22	Increased procedural services; see Anesthesia, Obstetrical Services, Robotic Assisted Surgery
25	Used with E/M codes only; see Injection/Infusion, Preventive, Prolonged Services, Rebundling
59	Distinct procedural service; many references including CCI Editing, Obstetrical, MPPR
TC	Technical component; referenced with IONM, MPPR, Professional/Technical Component
SG	Indicates facility services when submitted on CMS-1500

Provider Billing Notes and Actions

Billing Rule

Treatment of SG modifier on CMS-1500

Services reported on a CMS-1500 form with the SG modifier are treated as facility claims rather than professional claims. Do not bill these services under UnitedHealthcare Community Plan professional reimbursement policies when SG is present on the CMS-1500 (or its electronic equivalent).

Affected form: CMS-1500 (paper or electronic equivalent)
Modifier: SG indicates facility services — treat as facility claim
Operational impact: Not subject to UnitedHealthcare Community Plan professional reimbursement policies

Modifier Definitions

Modifier — definition and use

DefinitionA modifier provides the means to report that a service or procedure was altered by specific circumstances without changing its definition or code; it can convey additional information such as multiple performances, unusual events, multiple providers, or different locations.

PurposeUsed to indicate that a service was performed in a manner or circumstance that affects billing or reimbursement but does not change the procedure code itself.

Guidance ReferenceThis document is a reference tool; for complete information refer to the specific reimbursement policy and the Procedure to Modifier Policy for procedure‑to‑modifier guidance.

Reimbursement DetailsFor UnitedHealthcare Community Plan Medicaid reimbursement percentages, see the Modifier Reimbursement Grid in the Attachments section.

SG — definition and CMS‑1500 treatment

SG meaningSG indicates facility services when reported on a CMS‑1500 (1500 Health Insurance Claim Form) or its electronic equivalent.

Treatment on CMS‑1500Claims submitted on a CMS‑1500 with an SG modifier are not treated as professional claims and are instead treated as facility claims.

Impact on UnitedHealthcare Community Plan policiesWhen SG is present on a CMS‑1500 claim, the claim is not subject to UnitedHealthcare Community Plan reimbursement policies for professional claims.