CurrentUnitedHealthcarePolicy N/A

NYCDFHP Medicaid — Non‑Covered Codes

This policy lists procedure, HCPCS, CPT, and other billable codes that UnitedHealthcare (NYCDFHP Medicaid) does not cover; it applies to providers billing NYC Dually-eligible/Medicaid members under this plan.

Policy Summary

PayerUnitedHealthcare

PolicyNYCDFHP Medicaid — Non‑Covered Codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill or expect reimbursement for procedures listed on the non-covered codes list when providing services to NYCDFHP Medicaid members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~900number of codes listed

multiplecode systems

NYCDFHP-Medicaidpayer/program

Non-Covered Codes — Coverage Determination

Non-covered codes

The following codes are identified by UnitedHealthcare (NYCDFHP Medicaid) as not covered.

Comprehensive list of non-covered CPT, HCPCS, temporary, and other billable codes as enumerated in the source document (see referenced chunks).

Sample Non-Covered Codes

Sample of listed non-covered codesmixedNot Covered

11719
20560
33289
36410
G0101
G0402
90768

Provider Billing and Documentation Actions

Denial Risk

Non-covered codes list

Policy Summary

PayerUnitedHealthcare

PolicyNYCDFHP Medicaid — Non‑Covered Codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill or expect reimbursement for procedures listed on the non-covered codes list when providing services to NYCDFHP Medicaid members.

SourceLink

On This Page

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Non-covered codes (selected alphanumeric series): OOO1A, 0002A, 0003A, 0004A, OO11A, 0012A, 0013A, 0021A, 0022A, 0031A, 0034A, 0041A, 0042A, 0042T, 0044A, OO51A, 0052A, 0053A, 0054A, 0064A, OO71A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, OO91A, 0092A, 0093A, 0094A, 0104A, 0111A, 0112A, 0113A, 0121A, 0124A, 0134A, 0141A, 0142A, 0144A, 0151A, 0154A, 0164A, 0171A, 0172A, 0173A, 0174A, 0202U, 0507T
Non-covered codes (numeric series): 11719, 20560, 33289, 36410, 36416, 38207, 53854, 55706, 57170, 59051, 64624, 66988, 69209, 69990, 75571, 75572, 76390, 76391, 76978, 76981, 77061, 77062, 77071, 77086, 80050, 80055, 80074, 80201, 80322, 80327, 80328, 80329, 80330, 80331, 80332, 80333, 80334, 80338, 80339, 80340, 80341, 80342, 80343, 80344, 80355, 80357, 80360, 80366, 80368, 80369, 80370, 80371, 80372, 80373, 80374, 80375, 80376, 81005, 81443, 81500, 82164, 82542, 82642, 82652, 83088, 83698, 83700, 83701, 83704, 84145, 84150, 84228, 86023, 86077, 86078, 86200, 86317, 86331, 86343, 86352, 86694, 86695, 86885, 87632, 87633, 87913, 88289, 88300, 88323, 88325, 88329, 88331, 88332, 88333, 89320, 90461, 90668, 90901, 90912, 91300, 91301, 91302, 91303, 91305, 91306, 91307

Definitions and Code Status

Non-covered code — definition and scope

DefinitionCodes listed in this document are designated as non-covered under the UnitedHealthcare NYCDFHP Medicaid Non‑Covered Codes policy.

ScopeApplies to providers billing NYC Dually‑eligible/Medicaid members under the NYCDFHP Medicaid plan.

ContentsComprehensive list of procedure, CPT, HCPCS, and other billable codes that UnitedHealthcare (NYCDFHP Medicaid) does not cover (approximately 900 codes listed).

Action for providersDo not bill the plan for services reported with the codes enumerated in this non‑covered list; prior authorization or documentation requirements are not specified in this document.

StatusCurrent — codes are identified as not covered by UnitedHealthcare (NYCDFHP Medicaid).