Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

UHC: Payment for COVID-19 testing coverage, outpatient SNF

Previously, UHC would not reimburse for COVID-19 testing when done outside of a skilled inpatient stay at a SNF.

However, during the PHE, starting Jan 27,2020 and then renewed on April 21,2021, subject to further extension, UHC is going to pay for the COVID-19 testing that is done outside of the skilled inpatient stay at a SNF.

This change applies to the following Medicare Advantage Plans:

  • Medicare Advantage Plans
  • Dual Eligible Special Needs Plans (DSNP)
  • Chronic Special Needs Plans (CSNP)
  • UnitedHealthcare Assisted Living Plans (IE-SNP)
  • FIDE/MMP Plans

Plans that this change DOES NOT APPLY TO:

  • UnitedHealthcare Nursing Home Plans (ISNP)
  • UnitedHealthcare commercial plans
  • UnitedHealthcare Community Plans (Medicaid Only Plans)

UHC will re-process the claims, there is no further action needed.

UHC will reprocess claims previously paid at $0 to be reimbursed at 100% of the Medicare fee schedule. No action is required from affected SNFs for these adjustments.

The following codes are going be reimbursed at 100% of Medicare Fee Schedule:


COVID-19 testing performed during an approved skilled stay are subject to Centers for Medicare and Medicaid Services (CMS) consolidated billing rules and are not separately reimbursable, except for the UnitedHealthcare Nursing Home Plan (ISNP). New applicable CMS covered COVID-19 testing codes may be added periodically. We may add or remove codes from the following list, in accordance with CMS coverage guidelines.

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Posted in #unitedhealthcare, Updates

UHC: Inpatient Readmission Review Policy, Facility-new 09/1/2021

This policy will be applied to UHC commercial Facility claims, starting for DOS 09/01/2021 and thereafter.

The following guidelines will apply:

1.The same day readmissions with same or related condition are required to be combined and reported on the same institutional claim (UB04-claim form or electronic equivalent) to be eligible for reimbursement

2. Same day readmissions with unrelated condition are required to be reported with condition code B4 on the institutional claim in order to be eligible for reimbursement

3. Planned readmissions or leave of absences, are required to be combined and reported on the same institutional claim with occurrence code 74 to report the dates the leave began and ended.

Exceptions to this policy:

  • Admissions for chemotherapy or immunotherapy treatment
  • Admissions for substance abuse unit or facility
  • Admonitions to an inpatient rehab unit
  • Readmissions after a patient is discharged from hospital against medical advice


Posted in Insurance, Training, Updates

Anthem Medi-Cal: Hospital Reimbursement Policy Update- 05/01/21

Currently Anthem Medi-Cal reimburses for services for a covered member prior to admission to an inpatient hospital (referred to as the payment window) unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

However, Emergency and observation services are included in the inpatient reimbursement and, therefore, are not separately reimbursable expenses when performed within 24 hours prior to and including the day of the member’s admission.

Effective 05/01/21- Anthem Medi-Cal the following changes will take effect:

  1. For admitting hospitals: preadmission services are included in the inpatient reimbursement for the three days prior to and including the day of the member’s admission. Therefore, they are not separately reimbursable expenses.
  2. Anthem will not consider the following services to be included in the payment window prior to an inpatient stay for preadmission services:
  • Ambulance services
  • Maintenance renal dialysis services
  • Services provided by:
    • Skilled nursing facilities
    • Home health agencies
    • Hospices
  • Unrelated non-diagnostic services

If you have more information please visit: and review Preadmission Services for Inpatient Stays reimbursement policy