CurrentUnitedHealthcarePolicy 2025R0116C

Once in a Lifetime Procedures reimbursement on CMS-1500

Defines UnitedHealthcare Community Plan reimbursement rules for procedures billed on CMS-1500 (and when specified UB04) that are reimbursed only once during a patient's lifetime; applies to providers submitting claims for covered enrollees, with state exceptions for Arizona and North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicyOnce in a Lifetime Procedures reimbursement on CMS-1500

Policy CodePolicy 2025R0116C

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit accurate CMS-1500 claims; only one procedure per Code Family will be reimbursed per patient lifetime and the earliest processed duplicate across dates will be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

One-timeReimbursement frequency per Code Family during a patient's lifetime

2States with customized exceptions (AZ, NC)

4Example Code Family size shown in policy

Once in a Lifetime Reimbursement Rules

Once in a Lifetime reimbursement rule

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ALL of the following

If any single or multiple physicians or other qualified health care professionals report a code from the Once in a Lifetime Procedures list, that code or any code from the same Code Family will be reimbursed only once during the patient's lifetime.
UnitedHealthcare follows a 'first in, first out' claim payment methodology to determine which claim is considered for reimbursement when duplicate claims are received on different dates of service.
When multiple dates of service are submitted for the same Once in a Lifetime code, the earliest claim processed will be considered for reimbursement (FIFO).
If the same procedure code is reported on the same date of service by different physicians for the same patient, duplicate billing logic applies and the services are not reimbursed more than once.
Claims submitted for the same patient, same procedure code, and same date of service are evaluated under duplicate-billing rules rather than reimbursed multiple times.

Billing, Documentation, and Modifier Guidance

Billing Rule

Claims submission and duplicate handling

Submit accurate claims on the CMS-1500 form. UnitedHealthcare will reimburse only one procedure per Code Family during a patient's lifetime; when duplicate claims are received on different dates of service, the earliest claim processed (first in, first out) is considered for reimbursement. If the same procedure code is reported on the same date of service by different physicians for the same patient, duplicate billing logic applies and the claims are not reimbursed twice.

Documentation Required

Use of modifiers for subsequent reporting

Modifiers may be used to indicate an altered or discontinued procedure; for example, modifier 53 (Discontinued Procedure) may be appended to a CPT code to indicate the procedure was terminated and the CPT code may be submitted again later if the procedure is subsequently performed in its entirety, and will be considered under the Once in a Lifetime rule.

Scope and Administrative Context

This policy defines UnitedHealthcare Community Plan reimbursement rules for procedures billed on CMS-1500 forms and, when specified, UB04 forms. It applies to providers submitting claims for covered enrollees and establishes that certain procedures identified as Once in a Lifetime Procedures — including those grouped into Code Families — are reimbursed only once during a patient’s lifetime. UnitedHealthcare expects submission of accurate claims and uses CPT, CMS and other coding guidelines to determine appropriate reimbursement.

UnitedHealthcare may exercise reasonable discretion in interpreting and applying this policy for particular cases. Other factors — including federal or state regulatory requirements, provider contracts, the enrollee’s benefit design, and other reimbursement or medical policies — may supplement, modify or supersede the application of this policy.

State-customized exceptions exist: Arizona (AZ) and North Carolina (NC) use customized Once in a Lifetime procedure lists; providers should refer to the state-specific attachments for those lists when submitting claims in those states.

Attachments include the comprehensive Once in a Lifetime Procedures list by CPT code and Code Family and state-specific lists for Arizona and North Carolina. UnitedHealthcare may update this reimbursement policy and its implementation may vary across electronic claims processing systems.

Referenced Lists and State Exceptions

Attachments (referenced)

Once in a Lifetime Procedures listComprehensive list of Once in a Lifetime Procedures by CPT code and Code Family (referenced attachment).

Arizona Once in a Lifetime Procedure ListState-customized list for Arizona providing the Once in a Lifetime CPT codes and Code Families specific to Arizona.

North Carolina Once in a Lifetime Procedure ListState-customized list for North Carolina providing the Once in a Lifetime CPT codes and Code Families specific to North Carolina.