Reimbursement Policies for UnitedHealthcare Individual Exchange Plans
The UnitedHealthcare Reimbursement Policies are generally based on national reimbursement determinations, along with state government program reimbursement policies and requirements.
Please note that where a specific conflict between a provision of a contract between UnitedHealthcare and an applicable state program a provider contracts or state/federal regulations, such contract/regulation, will supersede these reimbursement policies.
UnitedHealthcare® Individual Exchange Reimbursement Policies Terms and Conditions
IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
You are responsible for submission of accurate claims requests. This reimbursement policy is intended to ensure that you are reimbursed based on the code that correctly describes the procedure performed. This and other UnitedHealthcare reimbursement policies may use CPT, CMS or other coding methodologies from time to time. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all professionals who deliver health care services. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy.
This information is intended to serve only as a general reference resource regarding UnitedHealthcare's reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. Further, the policy does not cover all issues related to reimbursement for services rendered to UnitedHealthcare enrollees as legislative mandates, the physician or other provider contract documents, the enrollee's benefit coverage documents, and the Physician Manual all may supplement or, in some cases, supercede this policy. Finally, this policy may not be implemented in exactly the same way on the different electronic claim processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations.
UnitedHealthcare may modify this reimbursement policy from time to time by publishing a new version of the policy on this Website; however, the information presented in this policy is believed to be accurate and current as of the date of publication.
UnitedHealthcare uses a customized version of the lngenix Claims Editing System known as iCES Clearinghouse (v 2.5.1) to process claims in accordance with UnitedHealthcare reimbursement policies.
"Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes on the UnitedHealthcare Bilateral Eligible Procedures Policy List describe unilateral procedures that can be performed on both sides of the body during the same session by the Same Individual Physician or Other Qualified Health Care Professional. CPT or HCPCS codes with bilateral in their intent or with bilateral written in their description should not be reported with the bilateral modifier 50, or modifiers LT and RT, because the code is inclusive of the Bilateral Procedure.",
The UnitedHealthcare Value & Balance Exchange policy is based on the Centers for Medicare and Medicaid Services (CMS) Multiple Procedure Payment Reduction (MPPR) Policy. UnitedHealthcare Value & Balance Exchange has adopted CMS guidelines that when multiple Diagnostic Cardiovascular Procedures or Diagnostic Ophthalmology Procedures are performed on the same day, most of the clinical labor activities are not performed or furnished twice.,
This policy addresses the reporting of pediatric and neonatal critical and intensive care services, Current Procedural Terminology (CPT®) codes 99468-99476 and 99477-99480, based on instruction from the American Medical Association (AMA) CPT book.,
UnitedHealthcare Reimbursement Policies are intended to serve only as a general reference resource for the services described. They are not intended to address every aspect of a reimbursement situation.
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.