According to the Centers for Medicare and Medicaid Services (CMS), medical and surgical procedures should be reported with the Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes that most comprehensively describe the services performed. UnitedHealthcare Medicare Advantage uses this policy to determine whether CPT and/or HCPCS codes reported together by the Same Individual Physician or Other Qualified Health Care Professional for the same member on the same date of service are eligible for separate reimbursement.,
For questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s health ID card.
Medicare Advantage Reimbursement Policies Terms and Conditions
Please read the terms and conditions below carefully.
The UnitedHealthcare Medicare Advantage Reimbursement Policies ("Reimbursement Policies") are applicable to UnitedHealthcare Medicare Advantage Plans offered by UnitedHealthcare and its affiliates.
You are responsible for submission of accurate claims. The Reimbursement Policies are intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. The Reimbursement Policies use Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS), or other coding guidelines. References to CPT® or other sources are for definitional purposes only and do not imply any right to reimbursement.
The Reimbursement Policies apply to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms (CMS 1450). Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing Reimbursement Policies.
Reimbursement Policies are intended to serve only as a general resource for the services described and are not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare may use reasonable discretion in interpreting and applying the Reimbursement Policies to health care services provided in a particular case. Further, the Reimbursement Policies do not address all issues related to reimbursement for health care services provided to UnitedHealthcare members. Other factors affecting reimbursement may supplement, modify or, in some cases, supersede the Reimbursement Policies. These factors may include, but are not limited to: legislative mandates, the physician or other provider contracts, and/or the member specific benefit plan documents**. Finally, the Reimbursement Policies may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare due to programming or other constraints; however, UnitedHealthcare strives to minimize these variations.
UnitedHealthcare may modify Reimbursement Policies at any time by publishing a new version of the Reimbursement Policies on this website. However, the information presented in the Reimbursement Policies is accurate and current as of the date of their publication. UnitedHealthcare regularly updates its Reimbursement Policies to comply with changes in CMS policy and other standard coding guidelines. UnitedHealthcare encourages physicians and other healthcare professionals to keep current with any CMS policy changes and/or billing requirements by referring to the CMS or your local carrier website regularly. Physicians and other healthcare professionals can sign up for regular distributions for policy or regulatory changes directly from CMS and/or your local carrier. UnitedHealthcare Reimbursement Policies do not include notations regarding prior authorization requirements. View services requiring prior authorization. Unauthorized copying, use and distribution of this information are strictly prohibited.
*CPT® is a registered trademark of the American Medical Association.
** For more information on a specific member's benefit coverage, please call the customer service number on the back of the member ID card or refer to the Administrative Guide.
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