CurrentUnitedHealthcarePolicy 2026R0127A

Procedure and Place of Service reimbursement for CMS 1500 claims

Governs reimbursement of CPT and HCPCS codes reported on CMS-1500 (professional) claims when submitted with an inappropriate Place of Service (POS); applies to UnitedHealthcare Commercial and Individual Exchange benefit plans and all network and non-network physicians and qualified health care professionals.

Policy Summary

PayerUnitedHealthcare

PolicyProcedure and Place of Service reimbursement for CMS 1500 claims

Policy CodePolicy 2026R0127A

Change TypeAdded Facility NA Indicator guidance

Effective Date

Next Review Date

Key ActionSubmit claims with accurate Place of Service codes per CMS POS guidance; codes with NonFacility or Facility 'NA' indicators will not be reimbursed in inappropriate POS.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Guidelines: Added Facility NA Indicator 'NA' information.

Attachments Section: Procedure and POS List Updated.

Template updated to indicate the policy applies to both UnitedHealthcare Commercial and Individual Exchange benefit plans.

CMS 1500claim form addressed

2026R0127Apolicy identifier

NonFacility 'NA'codes excluded

Facility 'NA'not reimbursed on professional claim with POS 21

Place of Service Reimbursement Criteria

Place of Service reimbursement criteria

Coverage is allowed only when the Place of Service (POS) reported on the claim is appropriate to the CPT/HCPCS code description, the CMS POS code set, and the CMS National Physician Fee Schedule (NPFS) 'NA' indicators.

Claim must be submitted on CMS-1500 (or electronic equivalent) with a two-digit Place of Service (POS) code per the CMS POS code set.

ALL of the following

Example: CPT code 94002 describes hospital inpatient/observation and is not appropriate for office or home POS.

UnitedHealthcare maintains attachments listing CPT/HCPCS codes and their appropriate places of service; providers should refer to the Attachments for code-specific POS guidance and the NPFS link.

Codes assigned the CMS NonFacility Indicator 'NA' will not be reimbursed when reported on a professional (CMS-1500) claim without an appropriate non‑facility POS.

Codes assigned the CMS Facility NA Indicator 'NA' will not be reimbursed when reported on a professional (CMS-1500) claim with facility POS 21.

Codes and NA Indicators

Codes with POS specified in description or guidelinesCPTCovered

94002

Ventilation assist and management, initiation of pressure or volume preset ventilators; hospital inpatient/observation, initial day — not appropriate for office or home POS

NA indicator exclusion

Policy exclusion summaryCodes with NonFacility Indicator 'NA' or Facility NA Indicator 'NA' will not be reimbursed when reported in an inappropriate Place of Service per policy.

NonFacility 'NA' exclusionCPT/HCPCS codes assigned NonFacility Indicator 'NA' are not reimbursed when reported on a professional claim without an appropriate non-facility POS.

Facility 'NA' exclusionCPT/HCPCS codes assigned Facility NA Indicator 'NA' are not reimbursed when reported on a professional claim with facility POS 21.

Reference for NA indicatorsNA indicators are defined in the CMS National Physician Fee Schedule Relative Value File; see Attachments for link to the NPFS file.

Billing Requirements and Reimbursement Denials

Denial Risk

Place of Service billing requirements and reimbursement denials for NA indicators

Providers must submit accurate claims using the CMS Place of Service (POS) code set. UnitedHealthcare will reimburse CPT and HCPCS codes only when reported with an appropriate POS; codes assigned NA indicators may be denied when billed in the incorrect setting. Ensure claims use the two-digit CMS POS codes on the CMS‑1500 or electronic equivalent.

Use the CMS POS code set (two‑digit codes) on CMS‑1500 or electronic claims.
CPT/HCPCS codes with a NonFacility NA indicator ('NA') are rarely/never performed in the non‑facility setting and will not be reimbursed when reported on a professional claim without an appropriate non‑facility POS.
CPT/HCPCS codes with a Facility NA indicator ('NA') are rarely/never performed in a facility setting and will not be reimbursed when reported on a professional claim with facility POS 21.

Key Terms and Indicators

Place of Service

DefinitionPlace of Service: A two-digit code used on health care professional claims to indicate the setting in which a service was provided.

Use on claimsReported on CMS-1500 (professional) claims or electronic equivalent to indicate where the service was performed.

AlignmentUnitedHealthcare requires POS to match CPT/HCPCS code descriptions, CMS POS code set, and NPFS NA indicators for reimbursement.

NonFacility/Facility NA Indicator

What NA indicatesCMS NPFS 'NA' indicates a procedure is rarely or never performed in the specified setting (non-facility or facility).

NonFacility NA'NA' for NonFacility indicates rarely/never performed in the non-facility setting; such codes won’t be reimbursed if reported without an appropriate non-facility POS.