Health Plan News

TMA payment specialists know how difficult it is to keep up with health plans’ constant changes. We are here to help you stay informed about the latest news from the major payers. Check back frequently for billing, coding, and health plan policy updates.

• Pediatric, Booster COVID Vaccine Codes Established 
  Now that federal health authorities have approved pediatric doses of the Pfizer COVID-19 vaccine, administrators of the vaccine should take note of these newly established CPT codes:

  Vaccine product code 
  91307– Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use

  Vaccine administration codes 
  0071A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose 

  0072A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose

  In addition, a new code has been assigned to the Janssen booster for the COVID-19 vaccine:

  0034A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x10¹⁰ viral particles/0.5 mL dosage; booster dose

  _{CPT copyright American Medical Association. All rights reserved.}           

• Use Correct Codes for HIV PrEP Services
  Aetna advises physicians billing for tests, services and medications related to HIV preexposure prophylaxis, or PrEP to avoid the general administrative code 96372. Find the correct codes, including associated ICD-10 codes, listed in a table in this OfficeLink Update. 
• 2026 Aetna Smart Compare™ Rankings Coming Soon 
  Aetna announced that evaluation notifications for its 2026 Aetna Smart Compare™ physician rankings, using claims data from 2023 and 2024, will begin in late 2025. The program “evaluates our participating providers, identifying those that meet higher standards of quality and cost-effectiveness,” per its Sept. 2025 bulletin. Physicians seeking to dispute Aetna’s ranking and tiering decisions prior to publication can request reconsideration within 45 days of receiving the written notice. “All reconsiderations begun in the first 45 days may lead to reversing our decision for your practice, regardless of the length of our exchange,” Aetna says in that update.
  
  The payer says it plans to use physician evaluations generated by its Smart Compare™ program in another new Aetna product: Informed Choice. Also launching in 2026, Aetna’s Informed Choice tool seeks to incentivize enrollees to choose certain physicians by offering them a lower copay if they choose a physician designated by Smart Compare™ as providing quality and effective care. As of this writing, Smart Compare™ and Informed Choice apply to physicians in certain specialties outlined its bulletin. 

• Aetna to Reduce Infusion Therapy Payment 
  On Sept. 1, report second and third concurrent infusion therapies, reducing the allowable payment by 25% for modifier SH and by 50% for modifier SJ, according to a recent health plan update. Aetna says the update will affect both commercial and Medicare members.

• Aetna to Cut Payment for Urgent Care Surgical Services
  Starting Sept. 1, Aetna will pay 75% of the contracted rate for surgical procedures performed in urgent care facilities or independent clinics with or without modifier 54, used to indicate surgical care, according to a recent health plan update. Aetna says the change is part its plans to expand its modifier 54 policy to include place-of-service codes 20 and 49, used when services are provided at an urgent care facility or at an independent clinic. The payer also will institute similar payment cuts for surgical procedures when billed by nurse practitioners or physician assistants.

• Aetna Reworking G0439 Claims Wrongly Denied
  Aetna on Jan. 30, 2023, began reworking certain claims with Healthcare Common Procedure Coding System code G0439 that were wrongly denied because of a software glitch. This code represents a subsequent Medicare Annual Wellness Visit (AWV) covered by Medicare Advantage plans. Aetna reported that its ClaimsXten clinical editing software was denying in error claims for this service when billed within 334 days of the previous AWV.

  Do not resubmit any claims with this denial, as Aetna will continue to rework and pay them until the software is fixed.

• BCBSTX Introduces Five New Claims Editing Rules  

  On or after Nov. 16, 2025, Blue Cross Blue Shield of Texas (BCBSTX) says it will update the Lyric software database "to better align coding" with the payment of claim submissions for primary and secondary editing, the latter of which will delineate ineligible reason codes with an alpha character of “L.” BCBSTX says it will implement the following new claims editing rules: 

  • Missing modifier 54: Identifies claims for surgical services provided in an emergency room where the follow-up care isn’t done by the same provider and Modifier 54 wasn’t billed;  
  • Sexually transmitted infection multi-code rebundles; 
  • Intensity modulated radiation therapy: Identifies codes submitted on an outpatient facility or professional claim when planning procedure 77301 is found within 30 days before or on the same date of service for the same provider; 
  • Trauma activation: Identifies claims with revenue code 068X and procedure code G0390 when submitted on an outpatient facility claim with no critical care procedure code 99291 on the same date of service; and 
  • Professional and technical component codes.  

  BCBSTX refers physicians to Clear Claim Connection™ to determine how coding combinations may be evaluated during claim adjudication, and to learn more about ClaimsXten and C3. 

• New Prior Auth Exemptions Reviewed by Blue Cross Blue Shield of Texas 
  Blue Cross Blue Shield of Texas (BCBSTX) says it has reviewed physicians for new prior authorization exemptions for particular health care services (i.e., a “gold card”) to be effective Aug. 29, 2025. Physicians can review their exemption status via the Provider Correspondence Viewer in Availity® Essentials.  Any requests for mail or email preference for prior authorization exemption communications submitted prior to July 18, 2025, will be sent via physicians’ preferences, per BCBSTX. Refer to prior authorization exemptions for more information.  

• BCBSTX Updates POS Code Guidance
  Blue Cross and Blue Shield of Texas (BCBSTX) reported on Nov. 29, 2023, that it is updating telemedicine and telehealth commercial claims filing guidelines for place-of-service (POS) codes to line up with recommendations from the Centers for Medicare & Medicaid Services, as follows:

  • Use POS 10 for telehealth provided in patient’s home.
  • Use POS 02 for telehealth other than in patient’s home.
    
    

  Source: BCBSTX

• Fee Schedules to Update Feb. 1, 2024
  Blue Cross and Blue Shield of Texas (BCBSTX) will change the maximum allowable professional and ancillary fee schedules – effective Feb. 1, 2024 – for these plans: Blue Choice PPO, Blue Essentials (including HealthSelect of Texas Network), Blue Premier, Blue Advantage HMO, Blue High Performance Network, MyBlue Health, and PAR Plan networks. See the payer’s General Reimbursement Information page for details and files (password required to view information. Contact your BCBSTX Network Management Office if you don’t have a password).

  You can request professional fee schedule(s) using the Professional Fee Schedule Request Form. Be sure to indicate your request is for schedule(s) effective Feb. 1, 2024.

  Source: BCBSTX

• Claim Editing Changes to Come for Emergency Department Services
  Beginning Nov. 1, 2023, Blue Cross and Blue Shield of Texas (BCBSTX) will change its claims editing and review process for emergency department evaluation and management (E/M) for some commercial plans.

  Under the change, your payment may be processed at a lower level of service if BCBSTX cannot validate the level of E/M services billed per the American Medical Association guidelines for level of service and medical decision-making.

  If you disagree with the payment received, you should submit additional medical records to support your claim for a higher level of service.

  For more information, see BCBSTX’s revised CPCP003 Emergency Department Evaluation and Management (E/M) Services – for Facility Services policy and new CPCP042 Emergency Department Evaluation and Management (E/M) Services Coding – for Professional Services. 

  Source: BSBSTXS

• Access Your Prior Authorization Info in a New Location
  You now can find all communications from Blue Cross and Blue Shield of Texas (BCBSTX) about your prior authorization (PA) exemptions in Provider Correspondence Viewer under the Payer Spaces section of Availity, including:

  • PA exemption notices effective Sept. 1, 2023;
  • All previously issued exemptions (effective Oct. 1, 2022, and March 1, 2023); and
  • Maintain or Rescission Audit Review Notices. 

  The previous Prior Authorization Exemption Status Viewer in Availity is retired.

  If you submit a request by specified deadlines for another preferred method of receiving your PA exemption communications, BCBSTX will also send future notices by that method.

  Source: BCBSTX 

• BCBSTX : Document Out-of-Network Referrals
  Be sure to fill out the appropriate Blue Cross and Blue Shield of Texas (BCBSTX) form when you refer a Blue Choice PPO or Blue Advantage HMO* patient to an out-of-network physician or provider, you are a participating BCBSTX physician, and an in-network option for referral is available.

  As applicable, fill out the Out-of-Network Care – Enrollee Notification form for regulated business (look for “TDI” on the patient’s ID Card) or for nonregulated business (no “TDI” on the patient’s ID card).

  Then give a copy of the completed form to your patient and keep a copy in the patient’s medical record files.

  *for Blue Advantage Plus point-of-service benefit plan

• New Health Plan for UT System Retirees
  Effective Jan. 1, 2023, University of Texas System retirees who are eligible for Medicare will receive health care coverage from UT CARE, a Blue Cross and Blue Shield of Texas (BCBSTX) open access Medicare Advantage PPO plan.

  These patients’ insurance ID cards will display the BCBSTX UT CARE logo and the words “Plan: Blue Cross Group Medicare Advantage Open Access (PPO).”

  BCBSTX says to get paid, follow the billing instructions on the ID card and submit the claims to BCBSTX.

  • Physicians who are contracted for any Blue Cross and Blue Shield (BCBS) Medicare Advantage plan will be paid their contracted rate.
  • Physicians who accept Medicare but are not contracted for any BCBS Medicare Advantage plan will be paid the Medicare-allowed amount for covered services, less any member cost share.

  Because this is an open access plan, plan members may see any physician or provider in the U.S. who accepts Medicare assignment. Members’ coverage levels are the same inside and outside their plan service area.

• Cigna to Deny Claims Without Z Code Documentation
  Starting July 14, 2024, Cigna Healthcare will begin to deny claims when certain E/M codes (99202-99215) are billed with a preventive service code and a supporting Z diagnosis code, but not supplemental medical record documentation. Physicians will need to refer to multiple policies by the payer to utilize both preventive services and problem-oriented E/M services for new and established patients on the same date of service, adding more tasks to physicians’ already exhaustive workload.

  Moreover, these services will not be payable by Cigna when billed with a Z diagnosis code alone, used to document social, environmental, and personal circumstances that influence a patient's health status, but are not diseases or injuries themselves. Instead, Texas Medical Association coding experts recommend billing supporting medical record documentation with the diagnosis code for the problem E/M claim in order to identify why a preventive service – like dietary counseling, for example – was performed.

  Physicians can also check Cigna’s preventive services policy for examples of Z codes or refer to Cigna’s E/M Reimbursement Policy for more payment information from the payer.

• Tips for Managing TPA Benefits
  Does your patient have Cigna Healthcare benefits managed by a third-party administrator (TPA)? 

  If your patient has a TPA-administered plan, you should contact the TPA – not Cigna Healthcare – for questions related to eligibility; benefits administration; claim status, payment, and administrative appeals; and precertification and prior authorization requests.

  Patients with a TPA Cigna plan will have an “S” on their ID card, along with contact information for the TPA. Or search for your patient on CignaforHCP.com; the Coverage Details screen will indicate if the patient has a TPA plan, and display the TPA name and phone number.

  Source: Cigna third quarter Network News, page 36.

• Primary Care Physicians Key to Effective Referrals
  Referrals to specialists typically originate with a patient’s primary care physician (PCP), who can ensure an effective referral by following these steps recommended by Cigna Healthcare:

  • Know referral requirements. First ascertain if your patient’s Cigna plan requires PCP referrals and in-network specialists. In any case, referring to an in-network specialist ensures the lowest out-of-pocket expenses says for your patient.
  • Prepare your patient. Make sure your patient understands the reason and importance for specialty care, and agrees to it and knows the next steps.
  • Provide a high-value referral request to the specialist office. Clearly state the clinical questions being asked of the specialist, and provide supporting data.
  • Define the specialist’s role. Be specific about what you’re asking the specialist to do, e.g., perform an evaluation or a specific procedure.
  • Close the referral loop. Track the referral to make sure the patient kept the appointment and the specialist has sent you a report. Be sure to acknowledge the specialist’s recommendations.
    
    

  Cigna does not require participating physicians to notify it of referrals to network-participating specialists, unless a patient’s benefit plan has a specific requirement to do so.

  Source and for more information: Cigna third quarter Network News, pages 11-12.

• Tools Aid in Care Coordination and Continuity
  Cigna has developed tools to serve as models for exchanging clinical information that can facilitate continuity and coordination of care during patient transitions. The payer says it based these tools on its quality program’s monitoring of:

  • Coordination of care during transitions between inpatient settings, in outpatient settings such as surgery or rehab centers or emergency departments, and when patients move between physicians;
  • Notification of patients and their transition from physicians Cigna has terminated from a network; and
  • Patients who qualify for continued coverage of services rendered by physicians Cigna has terminated from a network for reasons other than quality.
    
    

  The tools are available for download from CignaforHCP.com > Get questions answered: Resource > Medical Resources > Commitment to Quality > Quality > Continuity and Coordination of Care.

  Source: Cigna third quarter Network News, page 37.

• Humana to Update Prior Auth List
  Humana says it began updating its commercial prior authorization and notification list July 1, which includes delegating the review and management of requests for certain diagnostic, imaging, and sleep services to the clinical intelligence company Cohere. Practices billing for these services must send those requests to Cohere's online portal or call (833) 283-0033. TMA continues to monitor payers' use of artificial or augmented intelligence (AI).

• Beware of Services Not Payable With a Medicaid Child Checkup
  A Texas Medicaid policy may trip up physicians who perform child checkups under Texas Health Steps, the program that covers children aged 0 through 20 who are eligible for Medicaid.
  
  The policy says: “Components of a medical checkup that have an available CPT code are not reimbursed separately on the same day as a medical checkup,” with some exceptions (Section 5.3.6 THSteps Medical Checkup in the Texas Medicaid Provider Procedures Manual, Volume 2).
  
  For example, the Texas Health and Human Services Office of Inspector General recently sent a refund request on the basis of this policy to a physician who billed a Medicaid payer for audiometry (CPT 92551) with a child well-check.
  
  Exceptions under the policy are initial point-of-care blood lead testing, mental health screening for adolescents, postpartum depression screening, tuberculin skin test, developmental and autism screening, vaccine administration, and oral evaluation and flouride varnish. 

  _{CPT copyright American Medical Association. All rights reserved.}

• CMS Educates Physicians on How to Correctly Use & Bill for Remote Patient Monitoring on OIG’s Recommendation  
  In a September 2024 report, the Office of the Inspector General (OIG) within the U.S. Department of Health and Human Services recommended that the Centers for Medicare & Medicaid Services (CMS) improve oversight of remote patient monitoring in Medicare. Among other concerns, the OIG states it found about 43% of enrollees who received remote patient monitoring didn’t receive all 3 components of it – enrollee education and device setup, device supply, and treatment management.  

  As part of the OIG’s recommendation to strengthen oversight of remote patient monitoring, CMS shares the following education materials about correctly using and billing for remote patient monitoring: the Remote Patient Monitoring webpage and the Telehealth & Remote Patient Monitoring (PDF) booklet. 

• Medicare Increases Flu Vaccine Payment for 2025-26
  The Centers for Medicare & Medicaid Services (CMS) has increased Medicare payment for previously approved influenza vaccines, per the vaccine codes and pricing release for 2025-26. Find the most current list of billing codes, payment allowances, and effective dates under 2025-26 Flu Season Pricing Resources. Medicare will pay $11.03 to $98.16, up from last year’s $10.93 to $83.49 range. Per CMS, Medicare Part B covers the seasonal flu shot and will cover additional flu shots if medically necessary. TMA staff reminds physicians to use a national drug code (NDC) associated with the current period. 

  _{CPT copyright American Medical Association. All rights reserved.}   

• CMS to Deny Hospice Claims from Unenrolled Physicians Starting June 3
  Under a new requirement starting June 3, the Centers for Medicare & Medicaid Services (CMS) will deny hospice claims if a patient’s certifying physician isn’t enrolled in Medicare hospice services or has not opted out by that date. The requirement applies only to Medicare fee-for-service; no action is needed from physicians currently enrolled or opted out. It applies to claims made by hospice medical directors, patient-designated attending physicians, or physician members of a hospice interdisciplinary group who certify patients’ terminal conditions. The new requirement also:

  • Doesn’t prohibit the patient’s independent attending physician from treating them while in hospice and billing for those services under Part B; and
  • Applies to all written or oral certifications defined by CMS.

• CMS Updates DME Master List
  The Centers for Medicare & Medicaid Services (CMS) added 76 new items and deleted three from its master list of durable medical equipment (DME), prosthetics, orthotics, and supplies. CMS may require physicians to submit prior authorizations or written orders and undergo a face-to-face encounter with a patient to assess their condition prior to such equipment’s delivery. If so, clinicians ordering that equipment may be required to:

  • Meet with their patients and give them a written order before delivering the item; and
  • Ask their Medicare Administrative Contractor to authorize the item in advance.

  Visit TMA’s free Payment Resource Center for more information about medical equipment compliance.

• PLOS 10 Payments
  With the introduction of a new place of service (POS) code, practices should watch their payments to ensure they are correct. It is likely that PLOS 10 payments will be lower than the facility rate. The Centers for Medicare & Medicaid Services (CMS) and Novitas are reviewing guidance for a potential mass adjustment if it is determined that claims are processed incorrectly.
  

• Medicare Deductibles for 2024 See Increases
  The Centers for Medicare & Medicaid Services (CMS) has released the 2024 amounts for the Medicare Part A and Part B programs. The annual deductible for all Part B beneficiaries will be $240 in 2024 (an increase of $14 from the annual deductible of $226 in 2023). The Part A inpatient hospital deductible will be $1,632 in 2024 (an increase of $32 from $1,600 in 2023).

  Source: CMS Newsroom

• Prep for Novitas Smart Edits Feature Novitas Solutions’ Smart Edits, which will help you avoid denied electronic Medicare claims, will go live soon (exact date to be determined), and you can prepare now. Smart Edits will alert you of any Medicare claims you’ve submitted that can be repaired before a denial. The messages will display on the 277CA electronic claims acknowledgement response report and may require that you resubmit the claim.

  Here are some things you can do now:

  • Review the Smart Edit list and make any necessary corrections to your billing practice, so your applicable claims won’t be rejected once the edits are turned on.
  • If you are not familiar with the 277CA report, check with your billing department, or your billing service or clearinghouse. Novitas says this routine report, which advises whether claims submitted were sent to the processing system or not, is available shortly after submission. Claims rejected by a Smart Edit do not enter the claims processing system and are not assigned a claim number. The 277CA electronic report will provide a rejection code/flag. See the Novitas training module: Understanding the 277CA Claims Acknowledgement.
    
    
  Novitas shows how much time Smart Edits will save with a comparison example of the electronic claim flow with and without Smart Edits. Monitor the Novitas Smart Edits webpage for updates and information
  
• Use Correct POS Code for Medicare Telehealth 
  Although Medicare has recently implemented new place of service code 10 (telehealth provided in the patient’s home) to be effective April 4, 2022, physicians should follow the instructions from Novitas Solutions: Until the public health emergency is ended, continue to report the POS had that telehealth service been furnished in person. For example, if you typically see patients in your office, report POS 11 for a telehealth visit so Medicare will pay you the in-office rate. 
• CMS Debuts Coding Changes for Telehealth

• Fact Sheet Summarizes Medicare Payment for E&M Visits
  Medicare has generally adopted the new American Medical Association coding, language, and interpretive guidance framework for office and outpatient evaluation and management (E&M) visits (CPT codes 99201 through 99215), effective Jan.1, 2021. See this fact sheet for more information, including:

  • Payment of Medicare’s add-on codes for prolonged office and outpatient visits (G2212) and visit complexity (G2211), and
  • Medical review when time is used to select visit level. 
  _{CPT copyright American Medical Association. All rights reserved.}                                         

• Collect Medicare Info to Bill for Medicare Advantage COVID-19 Vaccine Administration
  Physicians contracted with Medicare Advantage plans should submit to original Medicare – not to the plan carriers – claims for administering a COVID-19 vaccine to their Medicare Advantage patients. To submit the claim to Medicare through Novitas Solutions, the Medicare payer for Texas, your practice will need to have on file your Medicare Advantage patient’s original Medicare card or Medicare ID number. Be sure to have your staff collect this when Medicare Advantage patients make appointments to receive a COVID-19 vaccine.
  
  Bill only for the vaccine administration when you’ve received the COVID-19 vaccine doses from the  government for free; don’t include the vaccine codes on the claim. Any other services you provide the patient on the same date should be filed to the Medicare Advantage plan. 

Molina Healthcare of Texas updates coming soon!

• Texas Shifts Dual-Eligible Medicaid Services to Managed Care 
  With state-approved Rider 32 implemented on Sept. 1, the Texas Health and Human Services Commission (HHSC) has transitioned Medicaid-only acute care services for dual-eligible individuals (those with both Medicare and Medicaid) from a fee-for-service model to a managed care delivery system. According to HHSC, physicians must submit claims for these services directly to the patient’s managed care organization (MCO), not to Texas Medicaid & Healthcare Partnership (TMHP) as done prior to Sept. 1. If submitted to TMHP in error, TMHP states the claim will be forwarded to the appropriate MCO for processing. Claim responses will show that the claims were forwarded, and TMHP will not generate an Electronic Remittance and Status (ER&S) Report. For a list of the procedure codes that were transitioned to MCOs, please view the Rider 32 Procedure Code List file.
• Superior Posts Behavioral Health Follow-Up Tips 
  Superior HealthPlan has posted a PDF on the website’s quality improvement page outlining tips for emergency department visits for mental illness and substance abuse and high-intensity care for substance abuse disorder, plus mental illness-related hospitalizations. Superior said in its announcement the guidance can “increase both eligible discharges and qualifying follow-ups, helping improve care and compliance for your patients.” The insurer also advises physicians to “provide timely submission of claims and code related diagnosis and visits correctly.”

• Superior Healthplan May Request Members’ Medical Records
  Superior Healthplan has announced that as of July 8, it may request medical records from physicians for patients in Wellcare By Allwell, STAR + PLUS Medicare-Medicaid, and Ambetter plans as part of an effort to conduct risk adjustments in accordance with Centers for Medicare & Medicaid Services and Health and Human Services payment methodology. The request will come to physicians via phone or fax from the third-party vendors Advantmed and Datavant, who will schedule medical record retrievals through:

  • Secure email;
  • Fax;
  • FedEx;
  • Remote electronic medical record download; and
  • Onsite scanning performed by an Advantmed medical record technician.
    
    

  TMA experts recommend physicians respond promptly to Superior’s scheduling requests as they may carry deadlines. According to the payer, any information shared during this process will be “kept in accordance with all applicable state and federal laws regarding the confidentiality of patient records, including current [HIPAA] requirements.”

  For any questions, email Superior.

• Send Claims to TRICARE or to Veterans Affairs – Don’t Double Bill
  Some TRICARE enrollees are eligible for health care through both TRICARE and the Department of Veterans Affairs (VA) Community Care program. For these dual-eligible beneficiaries, you can file a claim with only one federal agency for payment – either TRICARE or VA – but not with both. (Filing a claim with both payers for the same services could lead to duplicate payments and possibly the appearance that you are intentionally trying to double-dip from the federal government. That could lead to recoupment, administrative fees, penalties, and fines, or possibly even federal provider exclusion, suspension, or termination.)

  For nonemergency care for dual-eligible patients:

  • VA Community Care requires a VA referral for authorization, and TRICARE Prime requires referrals for most services. You must submit the claim to whichever agency provided the referral.
  • If you are unsure or there is no referral (not all TRICARE plans require one), ask the patient if they want to use their VA or their TRICARE benefit.

  For emergency care for dual-eligible patients:

  • Referrals are not required.
  • Ask the patient if they want to use their VA or their TRICARE benefit.
  • If the dual-eligible TRICARE sponsor does not respond, you must contact VA within 72 hours online or by calling (844) 724-7842 to authorize the care provided if you expect the patient to use their VA benefit.
  
  

  Source, and for more information and a decision tree: TRICARE Provider News, August 2023, page 4

• UHC National Gold Card Program Enters Second Year 
  On Oct. 1, UnitedHealthcare (UHC) started the second year of its national “Gold Card” program, which is a separate and distinct program than Texas’ gold-carding law. The insurer says additional provider groups will be eligible for its program this year due to another year of prior authorization submission data and general awareness of the program’s eligibility criteria.  More details, including eligibility rules and status, on the UHC Gold Card are available on the program’s webpage. 
• UHC to Implement New Lab Testing Policies 
  UnitedHealthcare (UHC) announced it will implement new routine laboratory testing policies starting Dec. 1 for certain services performed in office, hospital outpatient, and independent laboratory settings. UHC says the new reimbursement policies, which are available on its website (www.uhcprovider.com), provide guidance on reimbursement for tests based on circumstances and frequency. These policies will be enforced by “automated post-service, pre-payment policy” reviews of claims for the specific lab testing services listed on UHC’s September 2025 bulletin. These policies do not apply to emergency room, hospital observation unit or hospital inpatient settings, according to the UHC bulletin. 
• UHC Requires Electronic Submission of Claim Reconsiderations and Appeals for Texas Medicaid Programs 
  As of Aug. 1, UnitedHealthcare (UHC) says it requires pre-service appeals of preauthorization determinations, as well as claim reconsiderations and post-service appeals of claims, to be submitted electronically through the insurer’s portal for Texas Medicaid programs, including Children’s Health Insurance Program (CHIP), Medicare-Medicaid Plan, State of Texas Access Reform (STAR), STAR Kids, and STAR+PLUS. UHC says this change affects most physicians and facilities that provide services to UHC Community Plan members in Texas. Behavioral health and home- and community-based services are excluded from the change. Additionally, for CHIP, STAR, STAR Kids, and STAR+PLUS plans, physicians can opt out of the electronic submission requirement by filling out this form. For more information, contact the UHC help desk. 
• UHC to Enhance Certain Multiple Procedure Payment Reductions 
  Effective Nov. 1, UnitedHealthcare (UHC) announced it “will enhance” the Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy, Professional. According to its September 2025 Reimbursement Policy Update Bulletin, UHC says it will apply a reduction to certain ultrasound CPT codes to provide consistency with similar codes, and a modifier may be appended, “where appropriate,” to ultrasound procedures to indicate they were performed on the same date of service but in a separate session.  
• UHC National Gold Card Program
  

  The UnitedHealthcare national Gold Card program rewards contracted provider groups for consistently following evidence-based care guidelines. It applies to various UnitedHealthcare plans, including commercial, Individual Exchange, Medicare Advantage, and Community Plans.

  Effective March 17, 2025, the Gold Card code list has been updated to remove unused codes. The revised list is available on the program's information page.

  https://www.uhcprovider.com/en/resource-library/news/2025/national-gold-card-update.html?cid=em-providernews-2025nnb3-Feb25

• Email Authentication for UHC Portal to End March 6 
  Starting Thursday, March 6, physicians may no longer use an email address for recovery or multifactor authentication for the UnitedHealthcare (UHC) Provider Portal. UHC sent a reminder email on the subject on Feb. 17. The portal, used to complete tasks 24/7 such as checking the status of and submitting prior authorization requests, claims, reconsiderations, and appeals, will soon necessitate:

  • A One Healthcare ID. Physicians should register for their own if they currently share one.
  • Access to a mobile phone, direct landline phone number, or desktop authentication option.
  Effective January 2025, physicians will also need to download a recovery code. Find more access options on UHC’s site.

• UHC Requires New Modifier for Non-Covered Services
  Starting Feb. 1, 2025, United Healthcare (UHC) will require physicians to append a new GA modifier when charging UHC commercial plan members for non-covered services, including when a clinician knows or has reason to suspect that a commercial member’s benefits do not cover the service. Physicians also will need to acquire written consent from the patient for a service not covered by their benefits to meet documentation requirements.

  TMA billing staff say the change was made to align with guidelines by the Centers for Medicare & Medicaid Services. Per the payer, the new modifier requirement aims to help improve health care transparency by ensuring patients are made aware of their possible cost-sharing liability.

• UHC to Deny Claims Without JZ Modifier in Documentation
  Starting Oct. 1, United Healthcare (UHC) says it will require physicians to use modifier JZ when submitting claims to document when they’ve used all amounts of a drug in a single-use package or a single dose container. According to the payer, the update was made to align with guidelines from the Centers for Medicare & Medicaid Services. UHC says it will continue to require physicians to use modifier JW to indicate that they’ve discarded or used amounts of a drug from a single-dose container or single-use package.
• UHC to Deny Modifier 26 Radiology Claims without Proof of Interpretation

  Starting Oct. 1, to receive payment for claims appended with modifier 26, United Healthcare (UHC) has announced it will require radiologists to prove when they’ve provided a patient’s ordering physician with an interpretation and report of a radiology service such as by documenting the report in their electronic health record. If a radiologist performs a review of the service rather than a full written interpretation and report, the payer says it will consider the claims payment an evaluation and management (E/M) service and therefore not separately payable.

• United Slashes Prior Auth by 20%
  UnitedHealthcare (UHC) – Texas’ second largest health insurer by market share – has eliminated prior authorization requirements for certain procedure codes starting Sept. 1, 2023, across several of its national plans. The change is expected to reduce overall prior authorization volume by 20% and is part of an effort to “simplify the health care experience” for patients and clinicians, according to an Aug. 1 announcement.

  UHC eliminated the prior authorization requirements in two phases, on Sept. 1 and Nov. 1. The payer’s Medicare Advantage, commercial, Oxford, and individual exchange plans saw code changes on both dates. Its Community Plan was updated on Nov. 1 only.

  United urges physicians and practices to consult its code removal list for each health plan as “there will be some differences.”

  Starting next year, United also will implement a national gold-carding program for eligible clinician groups, with more information forthcoming.

  Source: UnitedHealthcare

• UHC to Require Digital Pre-Service Appeal Submissions
  Beginning Dec. 1, 2023, UnitedHealthcare (UHC) will accept only electronically submitted medical pre-service appeals from network physicians who have patients in UHC commercial, Medicare Advantage, and D-SNP plans. The payer encourages, but does not require, Community Plan (Medicaid) and out-of-network physicians to submit pre-service appeals electronically was well.

  To submit a pre-service appeal, use the Prior Authorization and Notification tool through the UnitedHealthcare Provider Portal.

  Source, and for details on how to submit: UnitedHealthcare

• VCP Statements Going Paperless for Medicaid Plan
  Beginning Nov. 3, 2023, UnitedHealthcare (UHC) will no longer mail virtual card payment (VCP) statements to UHC Community Plan (Medicaid) physicians who receive them by mail. Instead, you’ll access VCP statements in the Document Library in UHC’s Provider Portal. In the portal menu, select Documents & Reporting > Document Library > Payment Documents. When new statements become available in Document Library, UHC will send an email notification to the address on file.

  Remember, if you use an outside vendor, such as a revenue cycle management company or lockbox service, be sure they’re aware of this change.

  Source: UnitedHealthcare

• UHC to End Some Medicare Advantage Plans

  Effective Jan. 1, 2024, UnitedHealthcare (UHC) will reduce some Medicare Advantage service areas and discontinue some plans.

  The affected plans are certain AARP® Medicare Advantage plans, UnitedHealthcare MedicareDirect, UnitedHealthcare Dual Complete, or other UHC Medicare Advantage plans in multiple states.

  UHC says it will send nonrenewal notices to affected plan members dated Oct. 2, 2023, and let them know their options within UHC: other available Medicare Advantage plans, Medicare supplement insurance coverage, and Medicare Part D coverage, as applicable. These changes should not affect your participation agreement if you’re a participating physician with UnitedHealthcare Medicare Advantage, UHC says.

  Your patient may choose to enroll in a different organization’s Medicare Advantage plan or be returned to original Medicare on Jan. 1, 2024. Anyone can go to medicare.gov  for information about health plan availability.

  Source: UnitedHealthcare

• Medicaid Claim Letters Going Paperless

  Beginning Sept. 8, 2023, UnitedHealthcare (UHC) will no longer mail claim letters to physicians for UnitedHealthcare Community Plans (Medicaid).

  You’ll find these letters, including letters requesting additional information to process a claim, in the Document Library Claim Letters folder in the UnitedHealthcare Provider Portal.

  If you use an outside vendor, such as a revenue cycle management company or lockbox service, please ensure they’re aware of the following changes and digital workflow options.

  Source: UnitedHealthcare