Arkansas and Ohio New Observation Policy

Last modified: November 11, 2020

In Arkansas and Ohio, we’re implementing a new Outpatient Hospital Observation and Facility Reimbursement Policy (Observation Policy) starting Jan. 1, 2021 for our commercial members.

Action required

Under the new Observation Policy, observation services reported by facilities must be:

  • Reported with HCPCS code G0378 under revenue code 0762 (observation hours)
  • Submitted with bill type 13X or 85X
  • Reported with units based on the hours the patient is under observation care
  •  Submitted must equal or exceed eight hours (units)
  •  Submitted on the same date of service or the day after one of the following:
    • Emergency department visit
    • Clinic visit
    • Critical care
    • Direct referral for observation care
  • Reported on a single line and the date of service for that line is the date that observation care began

Observation services should not be:

  • Reported with a date span even when the period of observation spans more than one calendar day
  • Reported in addition to procedure codes assigned a status indicator J1 or T
    • Observation services are considered part of these services and not separately reimbursable

Reimbursement

When the criteria for the direct admission of a patient for observation care HCPCS G0379 is met, it should be reported in addition to the hospital observation service to be considered for reimbursement.

Claims for observation that do not align with the Observation Policy will be denied. You’ll have the option to resubmit the denied claim according to the terms of your contract and/or the UnitedHealthcare Administrative Guide.

As with all commercial plan policies, other factors affecting reimbursement may supplement, modify, or in some cases, supersede this policy. These factors include, but are not limited to, federal and/or state regulatory requirements, physician or other care provider contracts, medical policies, other reimbursement policies and/or the member’s benefit coverage documents.

We’re here to help

More information on our policies is available at UHCprovider.com Reimbursement Policies.

If you have questions, please contact your network representative or call Provider Services at 877-842-3210.