CurrentUnitedHealthcarePolicy 2025R0124B

Services and Modifiers Not Reimbursable to Health Care Professionals (CMS-1500)

Reimbursement policy governing which CPT/CMS status codes and modifiers submitted on the CMS-1500 (or electronic equivalent) will be denied or not reimbursed for UnitedHealthcare Commercial and Individual Exchange plans; applies to all physicians and other qualified health care professionals submitting claims.

Policy Summary

PayerUnitedHealthcare

PolicyServices and Modifiers Not Reimbursable to Health Care Professionals (CMS-1500)

Policy CodePolicy 2025R0124B

Change TypeClarified denial criteriaadded modifiers

Effective Date

Next Review Date

Key ActionDeny select NPFS status E and X codes and status M codes when reported on a CMS-1500 form.

SourceLink

POLICY UPDATE CHANGES

Removed Q Status Code reference from Reimbursement Guidelines section.

Attachments Section: Status M and Q lists updated.

Template updated to apply to both UnitedHealthcare Commercial and Individual Exchange benefit plans and Application section updated accordingly.

Modifier Section: Added modifiers HW & HY.

Policy clarifies UnitedHealthcare will deny select status indicator E and X codes and status M codes when reported on CMS-1500.

CMS-1500Form

Commercial & ExchangeProducts

E, X, MDenied statuses

HW & HYNew modifiers

Policy Summary

PayerUnitedHealthcare

PolicyServices and Modifiers Not Reimbursable to Health Care Professionals (CMS-1500)

Policy CodePolicy 2025R0124B

Change TypeClarified denial criteriaadded modifiers

Effective Date

Next Review Date

Key ActionDeny select NPFS status E and X codes and status M codes when reported on a CMS-1500 form.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Denial and Non-Reimbursement Rules

Denial and non-reimbursement criteria

UnitedHealthcare will deny reimbursement for certain codes and modifiers submitted on CMS-1500 forms based on NPFS status indicators and the funding source of services; applies to UnitedHealthcare Commercial and Individual Exchange plans.

ALL of the following

ONE OF
- Codes with NPFS status M (designated "for reporting purposes only") when reported on CMS-1500.
- Select codes with NPFS status E when reported on CMS-1500; refer to attachments for complete lists.
- Select codes with NPFS status X when reported on CMS-1500; refer to attachments for complete lists.
Codes appended with specified modifiers that indicate services funded by a county, state or federal agency (additional reimbursement not appropriate), except as noted for ambulance transport providers using modifier SE.
See policy modifier list/Attachments for specific modifiers (policy recently added modifiers HW and HY).

ALL of the following

Policy applies to claims submitted on the CMS-1500 form or electronic equivalent for UnitedHealthcare Commercial and Individual Exchange plans.
Refer to the Attachments section of this policy for complete lists of Status E, X, and M codes and the full modifier list used to determine denials.

NPFS Status Indicators, Payment Availability, and Codes

NPFS status indicator groupsmixedNot Covered

Status E	Select codes with Status E on NPFS denied when reported by health care professionals.
Status X	Select codes with Status X on NPFS denied when reported by health care professionals.
Status M	Status M codes are for reporting purposes only and will be denied when reported on CMS-1500.

Payment Availability

RVU and fee-schedule availabilityNo RVUs shown and no payment may be made under the fee schedule for NPFS-excluded status codes; payment when covered may continue under reasonable charge procedures.

Status M (measurement/reporting) codesDesignated for reporting purposes only; no RVUs or fee-schedule payment amounts are shown.

Statutory non-physician servicesSome status codes represent items/services not in the statutory definition of 'physician services' and therefore have no RVUs or payment amounts shown.

Billing and Submission Requirements for Providers

Denial Risk

Denial of select status E, X, and M codes

UnitedHealthcare will deny select CMS NPFS status indicator E and X codes when reported on a CMS-1500 form or its electronic equivalent. UnitedHealthcare will also deny codes designated with NPFS status M (designated “for reporting purposes only”) when reported on a CMS-1500; refer to the Attachments for complete lists.

Billing Rule

Modifier-based denials (government‑funded services) and SE exception

UnitedHealthcare will deny codes appended with specified modifiers that represent services funded by a county, state or federal agency when reported by any physician or other health care professional; ambulance transport providers using modifier SE are an exception. See the policy modifier list and Attachments for the complete modifier references.

Defined Terms

Same Individual Physician or Other Qualified Health Care Professional

DefinitionSame Individual Physician or Other Qualified Health Care Professional — the named physician or other qualified health care professional who provided the service and is the appropriate billing practitioner for that service.

Billing implicationClaims should be submitted under the same individual physician or other qualified health care professional when that practitioner actually provided the service.

Claim form contextApplies to services and modifiers billed on the CMS-1500 (or electronic equivalent) by physicians and other qualified health care professionals.