CurrentUnitedHealthcarePolicy 2025R5026A

Reimbursement for services by residents, interns, and medical students on CMS-1500

Governs reimbursement and claim submission rules for services billed on the CMS-1500 form (or electronic equivalent) involving residents, interns, and medical students for UnitedHealthcare Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement for services by residents, interns, and medical students on CMS-1500

Policy CodePolicy 2025R5026A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionAppend modifier GC or GE and include required teaching physician documentation when submitting claims for services involving residents or interns.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500claim form governed

390200000Xmedical student taxonomy code

GC, GEmodifiers accepted

Commercial & Exchangeplans covered

Coverage Criteria for Trainee-Provided Services

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Coverage criteria for trainee-provided services

UnitedHealthcare aligns with CMS regarding reimbursement for services involving trainees.

Services billed with the Medical Student taxonomy code (390200000X) are not reimbursed by UnitedHealthcare.

ALL of the following

The claim is submitted by a licensed practicing physician (teaching physician).
The claim is appended with modifier GC when the service was performed in part by a Resident under the direction of a Teaching Physician, or modifier GE when the service was performed by a Resident under the Primary Care Exception.
The Teaching Physician personally documents that they performed the service or were physically present during the key or critical portions of the service and provides independent documentation that corresponds to the Resident's documentation; without such documentation, no reimbursement can be made.

If a Teaching Physician was not involved with any part of the patient's care, services may not be reported on a CMS-1500 claim and will not be paid (except services qualifying under the Primary Care Exception reported with modifier GE).

Coding and Modifier Guidance

Medical student taxonomymixedNot Covered

390200000X

Student in an Organized Health Care Education/Training Program (medical student)

Teaching physician presence requirement (inv-03)

Reimbursement for services billed with Medical Student taxonomy (390200000X)Not reimbursed by UnitedHealthcare when the claim reports the medical student taxonomy code (390200000X).

Reimbursement when services involve Residents or InternsMay be considered for reimbursement only when claims are submitted by a licensed practicing physician with modifier GC or GE and required teaching physician documentation is present.

Teaching physician documentation requirementTeaching physician must personally document that they performed the service or were physically present during key/critical portions and provide independent documentation corresponding to the resident's notes; without this documentation, no reimbursement can be made.

Claims reporting restriction when no teaching physician involvementIf a teaching physician was not involved with any part of the patient’s care (except valid Primary Care Exception reported with modifier GE), services may not be reported on a CMS-1500 claim and will not be paid.

Claim Submission and Documentation Actions

Documentation Required

Claim Submission and Documentation Actions

Claims submitted by licensed practicing physicians for services rendered by residents or interns must be appended with modifier GC or GE to be considered for reimbursement. Modifier GC indicates the service was performed in part by a resident under the direction of a teaching physician. Modifier GE indicates the service was performed by a resident without the presence of a teaching physician under the Primary Care Exception. Teaching physicians must personally document that they performed the service or were physically present during key or critical portions of the service and their participation in the management of the patient. The teaching physician may refer to the resident's documentation, but must include an independent statement that corresponds to the resident's notes. Without this attending documentation, no reimbursement can be made. UnitedHealthcare aligns with CMS policies: services furnished by an unlicensed resident/intern where a teaching physician was not involved in any part of the care will not be paid (except when the Primary Care Exception applies and modifier GE is used).

Modifier GC — service performed in part by a resident under the direction of a teaching physician
Modifier GE — service performed by a resident without the presence of a teaching physician under the Primary Care Exception
Teaching physician must document personal performance or physical presence during key/critical portions and include independent documentation corresponding to the resident's notes
Claims without required attending documentation are not eligible for reimbursement
UnitedHealthcare follows CMS alignment: no payment when teaching physician not involved (except Primary Care Exception with modifier GE)

Definitions

Medical Student (inv-05)

DefinitionMedical Student: an individual enrolled in an accredited educational program (e.g., medical school) that is not an approved GME program.

Taxonomy code390200000X — Student in an Organized Health Care Education/Training Program (medical student).

Reimbursement noteServices billed with the medical student taxonomy code are not reimbursed by UnitedHealthcare.

Resident (inv-06)

DefinitionResident: an individual who participates in an approved Graduate Medical Education (GME) program, or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.

Reimbursement conditionServices rendered by residents may be reimbursed when billed by a licensed physician with modifier GC or GE and required teaching physician documentation is provided.

Role in careResidents participate in patient care under program oversight; billing must reflect teaching physician involvement per guidance.

Intern (inv-07)

DefinitionIntern: an individual (often a first-year resident) who is a licensed doctor but may practice medicine only with guidance and supervision.

Typical statusOften classified as first-year residents within training programs and work under supervision.

Billing implicationServices by interns are treated like residents for claim submission — reimburseable only when conditions for resident billing (modifiers and documentation) are met.

Teaching Physician (inv-08)

DefinitionTeaching Physician: a physician (other than another resident) who involves residents in the care of their patients.

Documentation responsibilityMust personally document that they performed the service or were physically present during key/critical portions and include independent documentation corresponding to the resident’s documentation.

Billing roleA licensed teaching physician may submit claims for services involving residents/interns when documentation and applicable modifiers are used as required.

Primary Care Exception (inv-09)

DefinitionPrimary Care Exception: a limited exception within an approved GME program where the resident is the primary caregiver and the faculty physician sees the patient only in a consultative role.

When it appliesApplies to residency programs with requirements incompatible with a physical presence requirement, allowing residents to see patients without supervision to learn medical decision making.

Modifier for claimsWhen used, claims should be appended with modifier GE to indicate services performed under the Primary Care Exception.

Physically Present (inv-10)

DefinitionPhysically Present: the teaching physician is located in the same room (or partitioned/curtained area) as the patient and/or performs a face-to-face service.

Documentation implicationPhysical presence during key/critical portions must be documented by the teaching physician for reimbursement when required.

Relation to modifiersIf the teaching physician is not physically present and the situation does not meet the Primary Care Exception, claims are not eligible for reimbursement unless proper documentation and modifiers (as applicable) are provided.