Non-Covered and Covered Codes Policy, Professional

1 Reimbursement Policy CMS-1500 Policy Number 2022R7102I Proprietary information of UnitedHealthcare Community Plan. Copyright 2022 United HealthCare Services, Inc. 2022R7102I Non- Covered and Covered Codes Policy, Professional IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or Codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicare and medicaid Services (CMS) or other coding guidelines.

2 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 health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. 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 Community Plan s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation.

3 Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, the enrollee s benefit coverage documents, and/or other reimbursement, medical or drug policies.

4 Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

5 Application This reimbursement policy applies to UnitedHealthcare Community Plan medicaid product. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Policy overview UnitedHealthcare Community Plan considers any CPT and HCPCS Codes that are not on a state medicaid fee schedule as not Covered for that state s medicaid market unless there are benefit &/or contractual agreements with negotiated rates.

6 Reimbursement Guidelines Not Covered Any CPT and HCPCS Codes that are not on the CMS NPFS but are on the state fee schedule will be Covered for that state s medicaid market. All Covered services are subject to all UnitedHealthcare Community Plan Reimbursement Policies and, although they will not deny as not Covered services, may deny based on another policy. Any CPT and/or HCPCS Codes that are not on the CMS NPFS, nor on an individual state fee schedule will deny as not Covered in that particular state unless there are benefit &/or contractual agreements with negotiated rates. Any code that is not Covered in any UnitedHealthcare Community Plan market will be on the UnitedHealthcare Community Plan Non- Covered Codes List.

7 Reimbursement Policy CMS-1500 Policy Number 2022R7102I Proprietary information of UnitedHealthcare Community Plan. Copyright 2022 United HealthCare Services, Inc. 2022R7102I NATIONAL Non- Covered Code P2031 Some medicaid markets have a listing of Covered Codes , rather than non- Covered Codes . For these States, there will be a Covered code list and any code not on the list will deny as not Covered . Category II Codes Category II Codes are used primarily for performance measurements and, per CMS, are not payable by Medicare. Upon review of the medicaid fee schedules, UnitedHealthcare Community Plan has determined that the Category II Codes are not payable in their medicaid markets.

8 Thus, Category II Codes will not be payable in any UnitedHealthcare Community Plan markets. Benefit Considerations The service requested must be reviewed against the language in the enrollee's benefit document. When the definitions of Experimental/Investigational Services and Unproven Services in the benefit document differ from the UnitedHealthcare Community Plan definition, it is the definition in the enrollee's benefit document that prevails. State Exceptions Arizona Arizona utilizes a Covered Codes List Indiana Indiana utilizes a Covered Codes List Kansas Kansas utilizes a Covered Codes List Michigan Michigan s Non- Covered Codes are not administered by this policy Minnesota Minnesota Utilizes a Covered Codes List Mississippi Mississippi CHIP (Plan ID MSCHIP) has a separate Non- Covered Codes List New Jersey Code S5151 is Covered for New Jersey medicaid Family Care only.

9 Category II code 3008F (Body Mass Index, documented) is payable for members ages 3 through 17 years, once per year, per provider when all the following criteria are met: 1. CPT Category II code 3008F-Body Mass Index Documented The diagnosis code must be primary for CPT 3008F for this incentive 2. One of the following evaluation and management services: 99201-99205, Office/Op Visit 99211-99215, Office/Op Visit 99241-99245, Consult/OP Visit 99382-99384, Initial preventive medicine/OP Visit 99392-99394, Comp preventive medicine/OP Visit 99401-99404, Preventive medical counseling/risk factor reduction 99411-99412, Preventive medical counseling/risk factor reduction 3.

10 One of the following ICD-10 diagnosis Codes : BMI, pediatric <5% BMI, pediatric 5% - <85% BMI, pediatric 85% - <95% BMI, pediatric >= 95% North Carolina North Carolina medicaid utilizes a Covered Codes list. Reimbursement Policy CMS-1500 Policy Number 2022R7102I Proprietary information of UnitedHealthcare Community Plan. Copyright 2022 United HealthCare Services, Inc. 2022R7102I Ohio Ohio utilizes a Covered Codes List Ohio s MME product (Plan ID OHMMEP) has a separate Covered Codes List Ohio 1951i utilizes the Ohio medicaid List HCPCs H0038, H0038HQ, H2023, H2025, and T1016 are also Covered for the Ohio 1915i product Pennsylvania Pennsylvania s Non- Covered Codes are not administered by this policy Rhode Island Rhode Island s Non- Covered Codes are not administered by this policy Tennessee Category II Codes 0500F and 0503F are Covered for Tennessee medicaid Texas Texas utilizes a Covered Codes List Per Texas medicaid Health Plan, effective for dates of service on or after January 1, 2015.