UHC Individual Exchange Plan Update

July 1, 2021
Rick Gawenda

UnitedHealthcare (UHC) Individual Exchange Plan has announced they will begin requiring additional modifiers be appended to CPT codes on both the 1500-claim form and UB-04 claim form in order for outpatient therapy services to be reimbursed. Failure to append the new modifiers on each CPT code will result in those claim lines being rejected.

The new modifiers that are required beginning with dates of service on and after

The content here is for members only log in here or sign up.

September 1, 2021 are either Modifier 96 or Modifier 97. Modifier 96 is to be appended to the CPT code on the claim form to indicate that the service is Habilitative in nature and Modifier 97 is to be appended to the CPT code on the claim form to indicate that the service is Rehabilitative in nature.

If additional modifiers are required to be appended to a CPT code on the claim form in addition to Modifier 96 or 97, then those additional modifiers must also be reported. This may include the discipline specific modifier (GN, GO, GP) or modifier 59.

Click HERE to read it straight from UHC.[restrict]

Thank you for being a Gold Member!

All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.

This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

  1. Would I be correct in stating that since I am in Arkansas, that we would still use the Commercial Plan policies, which have not indicated this change as of yet that I could find? or can you help clarify if the Exchange policy would appy here?

    When I looked up the UHC Exchange plan policies, I found this statement:

    apply to UnitedHealthcare Exchange Plans benefit plans in Arizona, Maryland, North Carolina, Oklahoma, Tennessee, Virginia, and Washington. For other states, please refer to Commercial Policies.

    1. Due to liability issues, I do not provide consulting services in this format and/or interpret their meaning based on your practice location.