Category: #unitedhealthcare

Find medical billing and coding guidance for UHC Insurance Payer (Commercial, Medicaid and Multiple States)

Posted in #reimbursement, #unitedhealthcare, Education, Payer Updates, Payers and CPT reinbursement

NJ Medicaid: Sickle cell Disease Generally Therapy- billing and coding

Posted on by KR2Medical Billing

Are you a provider in NJ that accepts NJ Managed Medicaid plans in your practice? Then this blog post is for you!

When: this applies for any services done on/and after Jan 1, 2026.

Who is eligible for reimbursement? Providers that are a member of the Center of International Blood and Marrow Transplant Research patient registry AND the provider must participate in the CMS study related to SCD gene therapies.

3. Which Plans- NJ Managed Medicaid Plans, ex. UHC Community Plan

Billing:

1. Professional Provider must bill on a separate professional claim (HCFA-1500)

2. Facility- drug must not be included on any facility claim, and added to any DRG or APC charges

3. SCD- must not be purchased at 340B program or be dispensed from 340B program inventory

Reimbursement:

4. Claims bust include the corresponding NDC, units, HCPCs and DX codes

Rebursement:

  1. The SCD is reimbursed at an invoice/ acquisition cost- the charges on the professional claim must equal to the Supplier invoice or the drug
  2. If the drug is billed through pharmacy (point of sale), the professional claim will not be reimbursed and will be processed as duplicate

Coding:

Please check out the following links for more coding info of the 2 drugs that fall under this policy:

Click to access billing-and-coding-guide.pdf

Lyfgenia Coding and Billing Resouces

Casgevy Billing and Coding Guide: https://www.casgevyhcp.com/sites/default/files/coding-and-billing-guide.pdf

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Posted in #Medicareadvantage, #unitedhealthcare, NY Providers, Prior Authorization Insurance Carrier Updates

UHC to remove prior auth for some radiology and cardiology tests.

Posted on by KR2Medical Billing

Starting Jan 1, 2026 certain nuclear imaging tests, OBGYN ultrasounds, and certain cardiology tests will no longer require a prior authorization for some of the  following plan types:

1.UnitedHealthcare Insurance Company
2.UnitedHealthcare Mid-Atlantic, inc. 
3.UnitedHealthcare Plan of the River Valley, Inc. and 4.UnitedHealthcare Insurance Company of the River Valley
5.Oxford Health Insurance, Inc.
United Healthcare Level Funded (formerly All Savers Life Insurance Company of California)
6.Neighborhood Health Partnership, Inc.
7.UnitedHealthcare Individual Exchange plans, also referred to as UnitedHealthcare Individual and Family ACA Marketplace plans
8.UnitedHealthcare Services, Inc.
9.UnitedHealthcare Community Plans

Some of the affected codes are:

Image via UHC website

For a full list of affected codes please click here: https://www.uhcprovider.com/en/resource-library/news/2025/removal-prior-auth-radiology-cardiology.html

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Posted in #reimbursement, #unitedhealthcare, Prior Authorization Insurance Carrier Updates

UHC Community Health Plan LTSS of DC: DME prior requirenments

Posted on by KR2Medical Billing

For some specific DME equipment, prior auth requirenments will align with durable medical equipment (DME) prior authorization requirements of the UnitedHealthcare® Dual Complete® Special Needs Plan (DSNP).

These requirenments take effect on 10/1/25 and apply to members with UnitedHealthcare Community Plan District of Columbia as well as integrated DSNP plans for Long-Term Care Services and Supports (LTSS).

Some of these DMEs are:

Patient lifts
Power wheelchairs
Respiratory support devices

Among others.

These prior authorization requirenments apply to the following codes:

To request an auth:

Phone: Call 888-702-2202

Fax: 866-968-7582. The fax form is available at Prior Authorization Forms on UHC website.

Or request the auth on the portal:

Sign in to the UnitedHealthcare Provider Portalopen_in_new with your One Healthcare ID

If you don’t have a One Healthcare ID, register now

From the left-hand tabs, select Prior Authorizations & Notifications

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