CurrentUnitedHealthcarePolicy N/A

Non-covered and covered CPT/HCPCS codes for UnitedHealthcare Community Plan Medicaid

Governs which CPT and HCPCS codes are considered covered or not covered for UnitedHealthcare Community Plan Medicaid products and how state-specific fee schedules or covered/non-covered lists affect reimbursement for UB-04 billed services.

Policy Summary

PayerUnitedHealthcare

PolicyNon-covered and covered CPT/HCPCS codes for UnitedHealthcare Community Plan Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReview enrollee benefit documents and state provider manuals; services not on state fee schedule or CMS NPFS may be considered not covered unless negotiated rates exist.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

UB-04claim form applicability

Community Plan Medicaidline of business

>20state lists referenced

multiple (2024–2026)version history

Coverage Determination

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.

Coverage determination flow

Determine coverage by checking CMS NPFS, the applicable state Medicaid fee schedule or the state's covered/non-covered code list and the enrollee's benefit document.

Coverage determination flow

ALL of the following

Is the code on the state Medicaid fee schedule?
If yes
- Covered for that state's Medicaid market; note: all covered services remain subject to UnitedHealthcare Community Plan reimbursement policies and may be denied under other policies
If no
- Proceed to check CMS National Physician Fee Schedule (NPFS)

ALL of the following

Is the code on the CMS National Physician Fee Schedule (NPFS)?
If yes
- Consider per CMS NPFS; check for state exceptions and other UnitedHealthcare reimbursement policies
If no
- If the code is not on NPFS but is on the state fee schedule, it is covered for that state's Medicaid market (see above)
- If the code is neither on NPFS nor on the state fee schedule, deny as not covered for that state unless there is a benefit and/or contractual agreement with negotiated rates

ALL of the following

Does the enrollee benefit document or state-specific guidance define Experimental/Investigational or coverage differently?
If yes
- Enrollee benefit definition or state-specific covered/non-covered lists prevail; providers must reference state provider manuals and enrollee benefit documents for specific coverage or program limitations
If no
- Use UnitedHealthcare Community Plan definitions and lists; codes not covered in any UnitedHealthcare Community Plan market will be listed on the Non Covered Codes List

Check state exceptions and lists

Some states utilize covered-code lists (codes not on the list deny as not covered) while others utilize non-covered lists; check state-specific attachments for exceptions (examples: Arizona, Kansas, Tennessee, Texas, etc.)

Code Lists and Fallback Rules

Coverage by code-list membershipmixed

CPT/HCPCS not on state Medicaid fee schedule	Codes not on a state's Medicaid fee schedule are considered not covered for that state's Medicaid market unless there is a negotiated rate or benefit agreement.
Codes on state fee schedule but not on CMS NPFS	If a code is on the state fee schedule but not on CMS NPFS, it will be covered for that state's Medicaid market but remains subject to other reimbursement policies.

Coverage determination fallback

Fallback denial ruleIf a CPT/HCPCS code is neither on the CMS National Physician Fee Schedule (NPFS) nor on an individual state Medicaid fee schedule, the code will deny as not covered in that state unless there is a benefit and/or contractual agreement with negotiated rates.

Exception — negotiated benefits/contractsCodes excluded from NPFS and state fee schedules may still be payable when there is an existing negotiated benefit or contractual agreement establishing coverage or rates.

State-specific covered-code approachIn some Medicaid markets that maintain a covered codes list (rather than a non-covered list), any code not on that covered list will deny as not covered for that state.

Non Covered Codes List placementAny code not covered in any UnitedHealthcare Community Plan market will be placed on the UnitedHealthcare Community Plan Non Covered Codes List.

Provider Claim Submission and Responsibilities

Note

Confirm state fee schedule, CMS NPFS, and enrollee benefits before claim submission

Review the enrollee’s benefit documents and the applicable state provider manual or state-specific covered/non-covered code list before submitting UB-04 claims; services not present on the state Medicaid fee schedule or CMS National Physician Fee Schedule (NPFS) may be denied as not covered unless a negotiated benefit or contractual agreement exists. Also note that codes on a state fee schedule but not on CMS NPFS are covered for that state's Medicaid market but remain subject to other UnitedHealthcare Community Plan reimbursement policies and may deny under those policies.

Check the enrollee benefit document and the state’s covered/non-covered code list or fee schedule prior to claim submission.
If the code is neither on the CMS NPFS nor the state fee schedule, expect denial as not covered unless there is a negotiated rate or benefit/contractual agreement.
Codes on a state fee schedule but not on CMS NPFS are treated as covered for that state but remain subject to other reimbursement policies.

Definitions and Non-covered Categories

Experimental/Investigational Services

Definition — Experimental/Investigational ServicesMedical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time of coverage determination, are not FDA‑approved for the proposed use, not identified in appropriate formulary/dispensing references, or are subject to institutional review board approval; FDA Humanitarian Use Device exemption devices are not considered Experimental/Investigational.

Examples includedMay include services, technologies, supplies, treatments, procedures, drug therapies, medications or devices under review or lacking required approvals for the proposed use.

Application of definitionThe Experimental/Investigational determination is applied at the time a coverage decision is made for a particular case.

Non-covered codes

Definition — Non‑covered codesCodes for services considered non‑reimbursable per state guidelines, CMS, or reimbursable by a payer other than UnitedHealthcare Community Plan.

Determination sourcesUnitedHealthcare follows state provider manuals, state websites or other regulatory materials to determine non‑covered codes for each state.

Scope and administrationPolicy is administered based on Date of Service; the Non Covered and Covered Codes provisions apply to outpatient claims (not inpatient).

State lists and attachmentsState‑specific lists (covered or non‑covered) are maintained as attachments; states that use non‑covered or covered lists are identified and governed by those lists when present.

Policy Summary

PayerUnitedHealthcare

PolicyNon-covered and covered CPT/HCPCS codes for UnitedHealthcare Community Plan Medicaid

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReview enrollee benefit documents and state provider manuals; services not on state fee schedule or CMS NPFS may be considered not covered unless negotiated rates exist.

SourceLink

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