Starting June 6, 2025, Texas Medicaid & Healthcare Partnership (TMHP) will add new Claim Adjustment Reason Codes (CARCs) to TexMedConnect. These new codes follow HIPAA rules and apply to Texas Medicaid.
Providers will find these new CARCs in the Adjustment Reason Code drop-down menu under the “Disposition” section in TexMedConnect.

This update enables TMHP to handle claims that include other insurance details in TexMedConnect. The way these claims are processed depends on the number of other insurance instances included in the Electronic Data Interchange (EDI) 837 claim transaction.

New CARC Codes

The Texas Medicaid & Healthcare Partnership (TMHP) will add the following Claim Adjustment Reason Codes (CARCs):

• 303: The previous payer's patient responsibility is not covered for those eligible for both Medicare and Medicaid.
• 304: These services are not covered under this plan. Please submit them to the patient's hearing plan for review.
• 305: These services are not covered under this plan, but the claim has been sent to the patient's hearing plan for further review.
• 306: The type of bill does not match the patient's status.
• P32: Payment has been adjusted due to apportionment.

Note

TMHP will deny claims submitted to Texas Medicaid or the Children with Special Health Care Needs (CSHCN) Services Program if they include other insurance information. This applies when the Claim Adjustment Reason Code (CARC) shows that the provider incorrectly billed the other insurance. Providers must find and fix any billing errors in claims sent to primary payers before submitting them to Texas Medicaid for payment review.

EDI Companion Guides Update

TMHP will revise the following EDI Companion Guides to reflect these changes:

• 837D Acute Care Companion Guide
• 837I Acute Care Companion Guide
• 837P Acute Care Companion Guide

For more details, contact the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.

 

Texas Medicaid MCOs are required to deliver all medically necessary services covered by Medicaid to their enrolled members. Administrative processes like prior authorization, precertification, referrals, claims, or encounter data submission may vary from traditional Medicaid (fee-for-service) and between different MCOs. Providers should reach out to the member’s specific MCO for more information.

On May 27, 2025, the Texas Medicaid & Healthcare Partnership (TMHP) revised the static fee schedules for hospital outpatient imaging and Indian Health Services.

Check the updates on the Fee Schedule Archives page, dated March 11, 2025, at tmhp.com.

For details, contact the TMHP Contact Center at 800-925-9126.

 

Start using the UnitedHealthcare Provider Portal to access AARP Medicare Supplement member information now. The AARP Healthcare Options Provider website will shut down on June 30, 2025. Sign up for the UnitedHealthcare Provider Portal before this date to ensure seamless administrative and patient care services.

What You Need to Know

You can now view AARP® Medicare Supplement member information on the UnitedHealthcare Provider Portal. Simply log in with your One Healthcare ID and choose the AARP Medicare Supplement Payer ID (36273). The portal’s easy-to-use tools let you quickly check member eligibility, claims, and payment details.

What's New

With the UnitedHealthcare Provider Portal, you can now:

• Check and print member ID card images
• See detailed benefit information
• View remaining deductibles for Medicare Supplement plans, if applicable
• Check ACH payment details
• Track claims that are acknowledged (received but not processed) or pending (in process but not finalized)
• Print summaries of benefits and claims
• Learn more about AARP Medicare Supplement plans

Having trouble signing in?

You might need to register first to use the UnitedHealthcare Provider Portal and see your member details.

How to Get Started

They can register today to use the portal. If sign-in issues persist, they should visit the One Healthcare ID help center or explore portal training resources, such as the Access and New User Registration Guide.

For questions about this process, they can refer to the contact resources for assistance.

 

Starting September 1, 2025, direct all billing for Medicaid-covered services and medications, including Medicare wraparound coverage, for Dual Special Needs Plan (D-SNP) members to UnitedHealthcare Community Plan of Texas. These updates are required under Texas House Bill 1 (Article II, HHSC, Rider 32).

Key Updates to Medicaid Billing and Services

• The Texas Health and Human Services Commission (HHSC) will cease managing billing and prior authorizations for Medicaid-covered services.
• Wraparound medications, including over-the-counter drugs, cough and cold remedies, and select prescription vitamins and minerals, will transition from fee-for-service (FFS) to the HHSC-established rate, with Optum Rx® overseeing medication billing.
• Medicaid-covered services will shift from FFS to a managed care billing model, aligned with the HHSC rate.
• Services for Medicaid-only beneficiaries, such as pediatric nursing facility care, provided through FFS, will remain unchanged.

Prior Authorization Details

Certain services and medications require prior authorization. Existing prior authorization requirements will remain unchanged. You can submit prior authorization requests via the UnitedHealthcare Provider Portal.

Easy Steps for Prior Authorization

• Visit UHCprovider.com and click "Log In" at the top-right.
• Sign in with your One Healthcare ID and password.
• New user? Register for a One Healthcare ID on the provider registration page.
• Go to "Prior Authorizations" in the menu.
• In the tool, find "Start a New Request" and click it.
• Enter the needed info and submit.

Learn more about using the UnitedHealthcare Provider Portal.

Helpful Resources

• Check the list of procedure codes needing prior authorization.
• See all Rider 32 procedure codes and the detailed list.

Questions?

Contact your Provider Advocate or call UnitedHealthcare Community Plan of Texas at 888-887-9003, Monday toFriday, at 8 a.m. to 6 p.m. CT.

 

From July 1, 2025, Rocky Mountain Health Plans plans to update the prior authorization procedures for a few of the CPT® codes when it is the primary payer. The chart inside this update lists the new CPT codes and their connections to prior authorization and notification requirements.

These updates affect the following Rocky Mountain Health Plans:

• Medicaid RAE/PRIME
• Child Health Plan Plus (CHP+)
• Medicare Advantage
• Dual Eligible Special Needs (D-SNP)
• Individual and Family Plans

Please keep in mind that the details may change and the list given here is not complete. People can see the list on July 1, 2025.

Rocky Mountain Health Plans Behavioral Health Codes and Authorization Requirements

CPT Code	Service	Prior Authorization and Notification Requirements
H2033, T2022	Multisystemic Therapy (MST), Enhanced MST	Pre-service notification required; authorization needed for services exceeding 90 days
H0036, T2022	Functional Family Therapy (FFT), Enhanced FFT	Pre-service notification required; authorization needed for services exceeding 90 days
G0137, H0015, Rev code 906	Substance Use Disorder Intensive Outpatient Programming (SUD IOP)	Pre-service notification required; authorization needed for services exceeding 15 sessions
S9480, Rev code 905	Behavioral Health Intensive Outpatient Programming (BH IOP)	Pre-service notification required; authorization needed for services exceeding 15 sessions
Rev. code 0911	Psychiatric Residential Treatment Facility (PRTF)	Prior authorization required
H0019	Psychiatric Residential Treatment Facility (PRTF)	Prior authorization required
H0017	All services associated with H0017, including the Acute Treatment Unit (ATU)	Prior authorization required
96132, 96133, 96136, 96137, 96138, 96139, 96146, 96130, 96131	Neuropsychological and Psychological Testing (and related codes)	Prior authorization required
96116, 96121	Neurobehavioral Status Exam	Prior authorization required

 

For any questions, please contact UHC at rmhp_updates@uhc.com.

 

All UnitedHealthcare Community Plan of New York contracted providers are reminded to ensure their practice data is accurate and current. This includes verifying and changing the office address, list of services, and whether to accept new patients. Maintaining correct data allows members to get the care they want with ease.

Every 90 days, UnitedHealthcare asks providers to confirm the information about their practice. Having correct listings is important since most people decide on their doctor depending on location, schedule, and what services are offered.

You can update your data either through the Identity Portal or by calling the agency.

My Practice Profile (MPP):

Those offering medical services can find MPP on the UnitedHealthcare Provider Portal at UHCprovider.com. After logging in with their One Healthcare ID, patients can access and change their profile details. If you haven’t set up a One Healthcare ID yet, go to the New User & User Access section on the website to do so. A detailed guide takes you through how to use MPP.

CAQH ProView®:

Many health plans use this as a way for doctors to instantly update their information online. Those with an account can already log in to CAQH and update their settings. People who are new to CAQH ProView should go to the website, make an account. They can also read through or watch the instructions in the user guide or video tutorial.

If you do not use MPP, you can insert updates with the practice change or demographic change form offered by UnitedHealthcare.

Properly handling your patient records helps give them the best health care. Providers are encouraged to use UnitedHealthcare’s contact resources page to find ways to get assistance or ask any questions.

 

Starting June 13, 2025, UnitedHealthcare will send fewer claim-related paper documents to most providers and facilities serving people with Medicaid in Kansas and Nebraska. As part of an effort to fast-track document access, providers in the UnitedHealthcare Community Plan will now experience this change.

Provider remittance advice, prior authorizations, overpayment requests, appeal decisions, and most claim letters will no longer be sent in the mail to providers in Kansas.

Nebraska will be moving its documents to digital format, and so will the virtual card payment (VCP) statements sent to people by mail. No changes in VCP will impact providers who make payments via Automated Clearinghouse (ACH) through direct deposit.

Rather than getting items through the mail, providers can look for them at any time on the UnitedHealthcare Provider Portal. Documents will remain in the portal’s Document Library for up to 24 months. All users will require a One Healthcare ID, and the Primary Access Administrator will receive email notifications when there are any new documents. One way to keep a large team informed is by using a single email address.

Large medical organizations can also utilize Application Programming Interfaces (APIs), which let data move automatically between systems. This helps to lower manual tasks and improve the workflow.

Coordinate with any billing or lockbox company your organization uses to make sure they’re set up for the new digital ways of billing.

Help for providers is available any time of the day via chat on the UnitedHealthcare Provider Portal or at Contact Us on the website.

It is meant to keep providers in order, allow them to react more quickly to updates, and cut down on forms in the two states.

 

To enhance provider enrollment efficiency and minimize claim denials, Maryland Medicaid is introducing a policy mandating unique National Provider Identifier (NPI) numbers for each practice location. This change complies with Centers for Medicare & Medicaid Services (CMS) standards and aims to synchronize our billing and enrollment systems. Full details are available in Section 7 of the 2024 Winter General Provider Updates.
Steps to Take

Secure a unique NPI for each practice location. Affected providers will receive a notification specifying when to update their Maryland Medicaid Provider accounts. Do not modify existing accounts until notified. To obtain additional NPI numbers, use the National Plan and Provider Enumeration System (NPPES) or contact 800-465-3203 or 800-692-2326 (NPI TTY).

No ePREP applications are required for updates. Once the Maryland Department of Health (MDH) receives your new NPI spreadsheet, it will update the billing and enrollment systems on your behalf. You’ll receive an email confirmation from mdh.npiuncollapsing@maryland.gov upon completion.

After receiving state registration confirmation, use the new NPI(s) as your service facility NPI on claims. Ensure your billing NPI and location address, including the ZIP code+4, align with the active record in the state’s ePREP system.

Purpose of the Change

Currently, some practices in ePREP lack unique NPIs for multiple locations, hindering location-specific service tracking. Mismatched ZIP codes between practice addresses and state records also frequently lead to claim denials.

Exemptions

This policy does not apply to hospitals, which may continue using a single NPI across enrollments, or to providers with a Type 1 Individual NPI.

Need Assistance?

Visit Maryland Medicaid FAQs or access 24/7 support via chat in the UnitedHealthcare Provider Portal.

 

To enroll in a UnitedHealthcare Chronic Special Needs Plan (C-SNP), Medicare beneficiaries must meet specific health criteria. CMS mandates confirmation from a treating provider that the applicant is diagnosed with at least one of the plan’s three qualifying chronic conditions.

• Diabetes mellitus (pre-diabetic conditions are not considered eligible)
• Cardiovascular diseases, including heart rhythm abnormalities, coronary artery disease, circulation issues like peripheral vascular disease, and chronic venous thromboembolic conditions
• Chronic heart failure

CMS regulations prohibit using past diagnoses from claims or other prior records to validate eligibility for C-SNP enrollment.

Upon receiving the application, UnitedHealthcare launches the verification process, which may begin before the member’s plan start date. The plan has a 60-day period post-effective date to secure confirmation of the qualifying condition. Our dedicated verification team will reach out to the member’s healthcare provider, either a primary care doctor or a specialist, to obtain the necessary documentation.

How Providers Can Confirm a Qualifying Condition

Healthcare providers need to fill out a Chronic Condition Verification Form and send it back in one of these ways:

• Call the phone number on the form and leave a message (doctors or nurses can do this).
• Email the completed form to mandrenrollment@uhc.com.
• Fax the form to the number listed on it.

If the condition isn’t confirmed within those 60 days, CMS requires the member to be removed from the C-SNP. So, if UnitedHealthcare contacts you about verifying a patient’s condition, please respond as soon as you can using one of these methods.

About C-SNP Plans

C-SNP plans are built to support people with chronic conditions, offering things like lower out-of-pocket costs for doctor visits and medications, tailored care management, and extra benefits such as credits for over-the-counter (OTC) items and healthy groceries.

 

Prior authorization is now required for physical, occupational, speech therapy, and chiropractic care provided in offices or outpatient hospital settings. This applies to UnitedHealthcare® Medicare Advantage members. Home-based services are not included.

What’s New?

Providers must obtain prior authorization for PT, OT, ST, and Medicare-covered chiropractic services for UnitedHealthcare Medicare Advantage members. This applies to services in office or outpatient hospital settings, but not home settings.

• The initial evaluation does not need prior authorization.
• First 6 Visits: Up to 6 visits within 8 weeks of a new plan of care are covered without a clinical review under these conditions:
  • The member is new to your office.
  • The member has a new condition.
  • There’s been a 90-day or longer gap in care.
  • Note: You must still submit a prior authorization request for these 6 visits.
• More Than 6 Visits or 8 Weeks: For plans with more than 6 visits or 8 weeks, CMS guidelines, InterQual criteria, and insight from licensed professionals (like chiropractors, physical therapists, occupational therapists, speech-language pathologists) will be used to determine if the care is medically necessary.
• Additional Visits: Providers must submit a fresh prior authorization form after the patients have been treated for six visits.

For a comprehensive overview of the requirements that began Sept. 1, 2024, see the Advance Notification and Clinical Submission Requirements. 

Why Does This Matter?

• Claims Impact: Without prior authorization, claims may be denied, and providers cannot bill the member (balance billing is not allowed).
• Timely Submission: Prior authorization requests must be submitted within 10 business days (14 calendar days) of starting services to avoid claim denials.
• Incomplete Requests: If a request lacks required information, UnitedHealthcare will contact the provider. If the information isn’t provided, the request may be denied.

Who Is Affected?

Plans Requiring Prior Authorization:

• Medicare Individual plans (including Chronic Special Needs Plans)
• Medicare Group Retiree plans
• UHCWest Medicare plans in Nevada, Oregon, Washington, and Texas

Plans Excluded:

• Out-of-network providers
• UnitedHealthcare Dual Complete (including Optum at Home)
• UnitedHealthcare Nursing Home and Assisted Living Plans
• Specific UHCWest plans in California and Arizona
• Erickson Advantage
• Peoples Health Plans
• Preferred Care Network and Preferred Care Partners of Florida
• Rocky Mountain Medicare Advantage Plans

Services Excluded:

• Inpatient therapy and therapy in home settings (follows existing Home Health prior authorization rules).
• Routine chiropractic services (a supplemental benefit not covered by Medicare, e.g., for pain relief or nausea) do not require prior authorization. However, Medicare-covered chiropractic services (manual spine manipulation to correct subluxation, billed with the AT-modifier) do require prior authorization.

Affected Services and Codes

These requirements only cover special outpatient therapy and Medicare-covered chiropractic services:

• Outpatient therapies: 92507, 92508, 92526, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97799, G0283
• Chiropractic services (Medicare-covered): 98940, 98941, 98942 when billed with the AT-modifier

Places of Service Requiring Authorization:

• Office (Code 11)
• Off-Campus Outpatient Hospital (Code 19)
• On-Campus Outpatient Hospital (Code 22)
• Ambulatory Surgical Center (Code 24)
• Independent Clinic (Code 49)
• Comprehensive Outpatient Rehabilitation Facility (Code 62)

How to Comply

1. Submit Prior Authorization:
   • Use the UnitedHealthcare Provider Portal (select “Submission & Status” under “PT, OT, ST Outpatient Therapy Transactions”).
   • Include the initial evaluation results and the full plan of care (duration and number of visits).
   • The treating therapy or chiropractic provider should submit the request.
2. Billing:
   • Use appropriate CPT codes with revenue codes to ensure proper claim processing.
   • Submit claims after receiving authorization to avoid denials.
3. Check Status:
   • Visit the Optum Physical Health webpage and use the activity center’s “Check Status” link to track submissions.
   • Once complete, you’ll receive a summary and determination letter.
4. Appeals:
   • The Notice of Determination that is sent out following a denial will contain appeal instructions for providers and members.

Frequently Asked Questions

1. Do ongoing therapy patients need prior authorization?
   Yes, all therapy and Medicare-covered chiropractic services require prior authorization, but the first 6 visits within 8 weeks for new patients, new conditions, or after a 90-day gap are covered without a clinical review.
2. Can I start treatment on the same day as the evaluation? Yes, treatment can begin the same day, and up to 6 visits are covered without review, but you must submit a prior authorization request.
3. What if I need more than 6 visits? Submit a new prior authorization request for additional visits, which will be reviewed for medical necessity.
4. What happens if I don’t submit prior authorization? Claims may be denied, and you cannot bill the member.
5. Does this apply to multidisciplinary practices? Yes, practices offering PT, OT, ST, or chiropractic care (together or separately) must follow these rules for the listed place-of-service codes.
6. What about Skilled Nursing Facilities (SNFs)? SNFs billing with Part B bill types (e.g., 22X or 24X) do not need prior authorization.

Key Takeaways

• Act Fast: Submit prior authorization requests within 10 business days to avoid claim denials.
• Use the Portal: All requests must go through the UnitedHealthcare Provider Portal.
• Know the Rules: Initial evaluations are covered without prior authorization, and up to 6 visits within 8 weeks are covered without review for eligible cases.
• Stay Compliant: Ensure proper CPT and revenue codes are used to avoid claim issues.

For full details, visit UHCprovider.com or contact UnitedHealthcare/Optum for support.

• Providers contracted with UnitedHealthcare: 888-676-7768
• Providers contracted with Optum: 800-873-4575

This update ensures providers can navigate the new requirements while continuing to deliver quality care to Medicare Advantage members.