CurrentUnitedHealthcarePolicy UB04 Policy Number 2025F7023E

Reimbursement Policy — Outpatient facility modifiers 52, 53, 73, 74 (UB04)

Defines UnitedHealthcare Community Plan Medicaid reimbursement treatment for outpatient facility claims billed on UB04 (or electronic equivalent) when modifiers 52, 53, 73, or 74 are appended; applies to all network and non-network outpatient facility claims for the referenced products.

Policy Summary

PayerUnitedHealthcare Community Plan Medicaid

PolicyOutpatient facility modifiers 52, 53, 73, 74 reimbursement (UB04)

Policy CodePolicy UB04 Policy Number 2025F7023E

Change TypeState exceptions updated (non-material)

Effective Date

Next Review Date

Key ActionDo not submit modifier 53 on facility UB04 claims; submit appropriate modifier per CMS/AMA guidance and use modifier 74 when applicable for outpatient hospital reporting.

SourceLink

POLICY UPDATE CHANGES

State Exceptions updated on multiple dates (examples: 7/13/2025 Texas removed; 5/18/2025 Idaho updated; 5/11/2025 Kansas removed).

50%reduction in allowed amount for modifiers 52 and 73

denialsubmission of modifier 53 on a facility claim

no reductionmodifier 74 results in no reimbursement reduction

UH Community Plan Medicaidapplies to

Policy Summary

PayerUnitedHealthcare Community Plan Medicaid

PolicyOutpatient facility modifiers 52, 53, 73, 74 reimbursement (UB04)

Policy CodePolicy UB04 Policy Number 2025F7023E

Change TypeState exceptions updated (non-material)

Effective Date

Next Review Date

Key ActionDo not submit modifier 53 on facility UB04 claims; submit appropriate modifier per CMS/AMA guidance and use modifier 74 when applicable for outpatient hospital reporting.

SourceLink

On This Page

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Modifier reimbursement criteria

For outpatient facility claims billed on UB04 (or electronic equivalent) for UnitedHealthcare Community Plan Medicaid:

ALL of the following

Modifiers that reduce the allowable amount
- Modifier 52: When modifier 52 is present on a claim line the allowed amount will be reduced by 50%.50%
  Represents a reduced service; align with CMS guidance.
- Modifier 73: When modifier 73 is present on a claim line the allowed amount will be reduced by 50%.50%
  Represents a reduced service; align with CMS guidance.
Modifiers that result in denial on facility claim
- Modifier 53: Not appropriate on a facility claim; if submitted on a facility claim the claim line will be denied. Provider may resubmit with an appropriate modifier if applicable.
  Do not submit modifier 53 on UB04 facility claims; use modifier 74 when appropriate for outpatient hospital reporting.
Informational modifier (no reduction)
- Modifier 74: Informational on a facility claim; no reduction in reimbursement will be applied.
  Acceptable for outpatient hospital reporting when appropriate.

This policy applies to all UnitedHealthcare Community Plan Medicaid products and to all network and non‑network outpatient facility claims submitted on UB04 or its electronic equivalent.

Scope and application.

Outpatient facility modifiers and reduction rules

Outpatient facility modifiersModifierCovered

52	Reduction to be applied — allowed amount reduced by 50%
73	Reduction to be applied — allowed amount reduced by 50%
53	Facility claim with modifier 53 will be denied
74	Informational modifier — no reduction applied

Reduction percentage for certain modifiers (inv-03)

Reduction percentage (modifiers 52, 73)Allowed amount reduced by 50% when modifier 52 or 73 is appended to an outpatient facility claim line

Modifiers affectedModifier 52 and modifier 73 represent a reduced service and trigger the 50% reduction

Applies toOutpatient facility claims billed on UB04 (or electronic equivalent) for UnitedHealthcare Community Plan Medicaid products

AlignmentUnitedHealthcare will align with CMS when addressing these modifiers

Submission and billing guidance

Billing Rule

Modifier submission guidance

Submit the appropriate modifier per CMS/AMA guidance. Do not submit modifier 53 on facility (UB04) claims — submissions with modifier 53 on a facility claim line will be denied. Use modifier 74 as an informational modifier on facility claims when appropriate; no reduction to reimbursement will be applied for modifier 74. When modifiers that indicate a reduced service (for example, 52 or 73) are appended, UnitedHealthcare will apply a reduction to the allowable amount (typically a 50% reduction when modifiers 52 or 73 are present).

Do not submit modifier 53 on facility (UB04) claims — claim line will be denied if submitted.
Use modifier 74 on facility claims only when appropriate; modifier 74 is informational and will not reduce reimbursement.
When modifier 52 or 73 is appended on a facility claim line, a reduction to the allowable amount will be applied (reduction typically 50%).
Ensure modifier submission aligns with CMS/AMA guidance and payer-specific rules before filing or resubmitting claims.

Key definitions

Allowable Amount (inv-05)

DefinitionAllowable Amount: the dollar amount eligible for reimbursement to the physician or other qualified health care professional on the claim (examples: contracted rate, reasonable charge, billed charges as applicable)

Determination under contractsFor percent of charge or discount contracts, the Allowable Amount is the billed amount less the discount

ExamplesContracted rate, reasonable charge, or billed charges—whichever is applicable—may be used to define the Allowable Amount

PurposeUsed as the base dollar amount to calculate reimbursement adjustments (for example, reductions applied when modifiers 52 or 73 are present)