CurrentUnitedHealthcarePolicy N/A

Procedure-to-Modifier Reimbursement Policy — UnitedHealthcare Community Plan

Defines UnitedHealthcare Community Plan Medicaid rules for appropriate use of CPT and HCPCS modifiers on CMS-1500/UB04 claims and lists state-specific exceptions; affects all network and non-network physicians and qualified health care professionals for Community Plan Medicaid products.

Policy Summary

PayerUnitedHealthcare

PolicyProcedure-to-Modifier Reimbursement Policy — UnitedHealthcare Community Plan

Policy CodePolicy N/A

Change TypeAdministrative updates and state exceptions (no material coverage changes)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit accurate claims using codes and modifiers that correctly describe services on the CMS-1500 or electronic equivalent.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500forms/products governed

GN/GO/GPtherapy modifier requirement

state-specificgeographic variances

attachmentsattachments referenced

Modifier Usage and Change Log

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Modifier usage criteria and state exceptions

Modifiers must be used appropriately and may be required or disallowed per code, CMS guidance, and state-specific regulations.

UnitedHealthcare Community Plan will consider reimbursement for a procedure code/modifier combination only when the modifier has been used appropriately; procedure code reported with an inappropriate modifier may be denied or subject to other reimbursement policies.

Certain modifiers are required for specific services per CMS guidance: Effective for dates of service on or after July 1, 2020, codes designated by CMS as always therapy services must be reported with one of the HCPCS therapy modifiers GN, GO, or GP.

Some modifiers or modifier usages bypass this policy or are excluded; refer to the Modifier Bypass List and the UnitedHealthcare Community Plan 'Modifier Reference Policy' for listings of modifiers excluded from this policy or governed by other policies or attachments.

State-specific exceptions (examples)

North Carolina: CPT 96110, 96112, 96113, 96130 and 96131 with GT modifier are not payable in POS 03.
North Carolina: CPT codes 11055, 11056, 11057, 11719, 11720, 11721, and G0127 must be reported with Q7, Q8, or Q9 modifier; if not reported, they will deny.
North Carolina: Orthotic and prosthetic HCPCS codes that can be used for one side of the body must be reported with RT or LT modifier; if not reported, they will deny.
State examples: Arizona is excluded from the Always Therapy Required Modifier requirement per Arizona state regulations; other states (e.g., Florida, Hawaii, Idaho, Indiana, Kansas, Kentucky, New York, Rhode Island, Tennessee) have specific allowed/exempt modifiers or disallowed modifiers as listed in the state exception entries—providers must follow applicable state regulations.

Change log / administrative notes

Administrative change log and state exceptions updates; no clinical coverage criteria included in these entries.

Attachment updates: The Arizona Procedure to Modifier Table (Acute and LTC lists) has been updated repeatedly; attachments referenced in the Resources/Attachment section reflect these updates.

State exceptions updates: Multiple policy-version changes list state exceptions added, updated, or removed for states including Arizona, Florida, Texas, Wisconsin, Tennessee, Idaho and others; providers should consult the most recent attachments for current state-specific guidance.

History/archive notes: History sections indicate that entries prior to specified dates (examples: 12/7/2023, 11/23/2023, 11/9/2023, 10/26/2023, 10/5/2023, 9/24/2023, 9/21/2023, 9/7/2023, 8/17/2023, 8/10/2023, 7/27/2023) have been archived; see Resources/History for details.

Claims Submission and Attachment Updates

Documentation Required

Claims submission responsibility

You are responsible for submitting accurate claims on the CMS-1500 (or electronic equivalent). Ensure codes and modifiers reported reflect the services provided and follow CPT, CMS and UnitedHealthcare Community Plan coding guidance. Inaccurate or inappropriate modifier use can result in denied or adjusted reimbursement.

Submit claims on CMS-1500 or electronic equivalent.
Follow CPT, CMS and UnitedHealthcare Community Plan coding guidelines.

Billing Rule

Modifier applicability

Modifiers must be applied correctly for reimbursement. UnitedHealthcare Community Plan will consider reimbursement for a procedure code/modifier combination only when the modifier has been used appropriately. Some modifiers are restricted by code (Modifier Bypass List) or by state-specific rules. When CMS designates codes as "always therapy services," the corresponding therapy HCPCS modifiers (GN, GO, or GP) are required for dates of service on or after July 1, 2020.

Modifier Bypass List: UnitedHealthcare will only reimburse procedure code/modifier combinations when the modifier is appropriate for that code.
Modifier 25 should be appended only to qualifying E/M services — not to procedure codes that the modifier description does not support.
Therapy modifiers GN (speech-language pathology), GO (occupational therapy) or GP (physical therapy) are required on CMS-designated always-therapy codes for DOS on/after 2020-07-01.
Refer to the UnitedHealthcare Community Plan Modifier Reference Policy for modifier-specific rules and to the attachments for lists of codes requiring or prohibited with specific modifiers.
When no definitive third-party industry source exists, follow interpretive guidance consistently and document rationale in the medical record.

Note

Attachment and State Exceptions updates

Attachment tables and state exceptions have been updated — notably Arizona Procedure to Modifier tables for Acute and LTC settings — and several state exception entries were revised or archived. Review attachments and state-specific sections to confirm modifier applicability and any state-level prohibitions or special requirements.

Attachment updates: Arizona Procedure to Modifier Table - Acute List and Arizona Procedure to Modifier Table - LTC updated.
State Exceptions updated for Arizona, Florida, Texas, Wisconsin, Tennessee and others as noted in the Resources/History.
Historical entries prior to listed archive dates have been archived; check current attachments for the authoritative lists.

Key Terms

Modifier — definition and purpose

DefinitionA modifier provides the means to report or indicate that a service or procedure performed has been altered by specific circumstances without changing its definition or code.

PurposeTo report additional information about a service (e.g., performed more than once, unusual events, multiple providers or locations) to ensure correct reimbursement and coding interpretation.

Use with codesModifiers must be used appropriately with CPT and HCPCS procedure codes; an appropriate modifier does not change the code definition but provides context for payment and edits.

Definitive vs Interpretive Source — distinction and use

Definitive SourceContains exact codes, modifiers, or very specific instructions from the given source and is used to establish direct code/modifier relationships.

Interpretive SourceBased on interpretation of guidance where no exact code or modifier is listed; requires correlation of codes to guidelines and may apply interpretation to surrounding or similar codes.

How usedUnitedHealthcare Community Plan sources procedure code-to-modifier relationships from third-party methodologies that can be definitive or interpretive; definitive sources yield exact mappings while interpretive sources require judgement.

Policy posting and resource notes

Posted byUnitedHealthcare Community & State

Resource updatesAttachment Section updated: Arizona Procedure to Modifier List updated (multiple entries noted).

HistoryHistory section entries prior to archived dates are noted (examples: entries prior to 5/19/2022 archived).

OpenPayer

Procedure-to-Modifier Reimbursement Policy — UnitedHealthcare Community Plan

Modifier Usage and Change Log

Modifier and Code Guidance

Claims Submission and Attachment Updates

Key Terms