CMS published its proposed rule for the 2026 fiscal year IPF regulations on April 11, 2025. The proposed rule of 2026 introduces updated Medicare pay rates and facility-based adjustments with new quality reporting standards and a feedback request from the public.
CMS proposes to increase IPF payment rates by 2.4 percent starting from FY 2026. Payment rates for IPFs will increase by 2.4 percent according to CMS's proposed rule for fiscal year 2026, which was calculated through a 3.2 percent market basket increase minus a 0.8 percent productivity adjustment. Medical establishments are projected to receive an estimated $70 million more in payments based on the projected rate increase during FY 2025.
CMS implements updated payment adjustment models alongside its planned rate increase. Through analysis of 2020 to 2022 data, CMS proposes increased payment adjustments for rural facilities and institutions serving as teaching hospitals. CMS proposes augmenting the maximum teaching limit for total full-time resident equivalents.
CMS proposes modifications to performance metrics for the IPF Quality Reporting Program. For improved performance assessments, CMS proposes extending the emergency department visit measure reporting window from yearly to two fiscal years. Starting with the 2024 reporting year, CMS will remove four quality metrics, including health equity measures and the COVID-19 vaccination coverage requirement, from its collection protocols.
The regulatory procedures for federal healthcare providers currently receive CMS evaluations based on Executive Order 14192, which CMS issued on January 31, 2025. Comments about the proposed rule must be submitted to the agency by June 10, 2025.
Additional details about the proposed rule and accompanying fact sheet are available through the CMS website.
Healthcare providers can access free training materials through Optum that explain how to merge behavioral health services with primary care practice. The training platform operates on demand while focusing on improving healthcare results and community wellness.
The Behavioral Health Identification Treatment and Referral in Primary Care series provides education to a broad spectrum of healthcare professionals, including doctors, physician assistants, nurses, nurse practitioners, social workers, and psychologists. Behavioral health identification and treatment, along with the proper referrals within primary care settings, form the core focus of this program.
The training includes three sessions:
The educational sessions teach practitioners about mental health screening procedures alongside referral practices and diagnostic procedures, and treatment strategies. The program connects with HEDIS metrics, allowing the tracking and enhancement of care quality.
Sessions enable participants to gain between 1.00 and 1.50 continuing education credits. Healthcare providers can obtain continuing education credits through the program, including CME for medical doctors alongside NCPD for nurses and APA for psychologists, and ASWB for social workers. The program requires no paid participation or continuing education credit costs.
Medical providers can use this training as an important resource to develop robust behavioral health services in their clinics. The system helps mental health providers work better together with physical healthcare providers to share patient information.
Medical staff members can enroll immediately and get free access to the training module series. More information about this training can be obtained by sending inquiries to moreinfo@optumhealtheducation.com.
In Florida, UnitedHealthcare introduced extended Community Plan benefits to enhance both patient access to care and health outcomes for members. These updated changes focus on making care plans more accessible for patients and offering doctors new tools to treat their patients effectively.
Healthcare professionals who deliver patient care experience benefits through these changes. UnitedHealthcare rewards primary care physicians through their CP-PCPi (Community Plan Primary Care Professional Incentive) performance incentive program. Through Practice Assist, healthcare providers can track patient requirements to decrease documentation work and improve the quality of care. Members can access free education programs at Optum Health Education.
The health insurance provider UnitedHealthcare introduced its new changes to offer improved patient care and better medical treatment delivery for doctors. Find additional information at the Florida health plan page and Section 52 of the UnitedHealthcare Community Plan of Florida Statewide Medicaid Managed Care Provider Manual.
To ensure UnitedHealthcare Community Plan of Kentucky members are assigned to the primary care provider (PCP) most involved in their care, UnitedHealthcare has updated its attribution process.
Starting March 1, 2025, UnitedHealthcare will conduct quarterly reviews of claims from the past 24 months to check if a member is regularly seeing a non-assigned PCP. If a provider is treating patients not currently assigned to their practice, UnitedHealthcare may reassign those patients to that provider. This change aims to improve health outcomes and streamline care management.
Claim Look-Back Exclusions
Claims for primary care services from the following facilities will not be included in the 24-month claim look-back and will not be considered for member reassignment:
Specialties Eligible for Attribution
The following practitioner specialties may be eligible for member attribution:
Questions?
For any questions, providers should contact Provider Services at 866-633-4449.
Applies to CPT® codes 81422 and 81479
To meet state requirements, starting June 1, 2025, UnitedHealthcare Community Plan of Maryland requires prior authorization for two types of Non-Invasive Prenatal Testing (NIPT) for its members. This applies to CPT codes 81422 and 81479 when used for:
How to Submit a Request
If UnitedHealthcare does not receive a prior authorization request before the service date, it will deny the claim, and the provider cannot balance bill members.
Resources
Questions?
For any questions, providers should visit the Prior Authorization and Notification page.
For UnitedHealthcare Individual Exchange plans (also called Individual & Family ACA Marketplace plans), prior authorization is required for total joint replacement procedures. Providers requesting these procedures (CPT codes 27445, 27447, 27130, and 27132) due to osteoarthritis may need to submit additional medical documentation. This applies nationwide, and no new codes are being added to the prior authorization list. Requests will be evaluated based on specific policies.
Summary of Changes
Hip Surgery: Providers must submit medical notes that include:
Knee Surgery: Providers must submit medical notes that include:
Conservative Care Requirements (Unchanged):
Clinical notes should clearly show the following treatments from the past year:
Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal. For additional contact information, visit the contact us page.
The Ohio Department of Medicaid website provides guides, past webinars, and answers to frequently asked questions regarding the EVV system for providers to access. Current preparations by healthcare providers will help prevent future claim problems while maintaining compliance with state and federal requirements.
UnitedHealthcare introduced electronic submission of unsolicited claim attachments as a new business option for healthcare providers. The addition of Availity to the EDI 275 transaction clearinghouse approval list speeds up and simplifies the process of sending claims.
Healthcare providers have access to EDI 275 for electronic submission of claims documentation that replaces the need for postal mail services. The electronic submission method lowers procedural mistakes and shortens reimbursement cycles while enabling providers to retrieve their payments faster. Providers who use electronic document submission become more efficient in billing operations because they prevent delays and reduce requests for missing information.
Several important advantages accompany the use of EDI 275. Secure information delivery happens without printing or mailing requirements. The transaction maintains an electronic log that serves as documented evidence for the delivery and receipt of the items. Medical claims process more quickly as a result of reduced follow-up activities.
UnitedHealthcare accepts EDI 275 document attachments through these clearinghouses:
Providers need to contact the clearinghouse with which they already work to enable EDI 275 functionality.
The UnitedHealthcare Provider Portal gives providers an alternative option to upload supporting claim documents even when they do not utilize a clearinghouse system. Both solicited and unsolicited attachments are accepted by this procedure.
The implementation of Availity has provided providers with multiple flexible options to handle claim attachments efficiently. This enhances their billing process.
UnitedHealthcare Community Plan requires all Ohio home health providers who work with them to establish EVV system access through Sandata beginning June 1, 2025. The state-wide implementation supports the 21st Century Cures Act by working to enhance home- and community-based service quality through increased accountability.
Home health providers risk denial of claims for their home health services when they neglect to use the EVV platform for visit recording. The service codes that require EVV proof include:
As a requirement of compliance, providers must complete their Sandata registration first through the official EVV Portal. Providers who complete their registration must finish brief training before they can start working with the platform.
If you have any questions, providers can email ODMCustomerCareEmail@Sandata.com or call 855-805-3505. You can also visit the UnitedHealthcare Provider Portal.
Medical practitioners need to document every home health visit after they receive system access permission. The visit documentation submitted to claims processing must correspond exactly to the information entered in the system. The claim will face denial because of a visit recording issue or a mismatch between the recorded information and the submitted data.
UnitedHealthcare Community Plan in New York adjusted the process of getting referrals for Medicaid beneficiaries under its system. It works towards simplifying patient care access while minimizing administrative work for health providers.
Specialty services now require no referral from primary care providers for their main condition for care. Most UnitedHealthcare Community Plan New York Medicaid members can visit specialists directly instead of waiting for first approval from their primary care provider. The 15 specialty areas are the only ones that need a referral because other specialties are now accessible without approval.
These specialties include:
Inside the UnitedHealthcare Provider Portal, healthcare providers can transmit their referral submissions to achieve authorization. Providers accessing the UHC provider website should navigate to the Sign In function located within the top right section. The website provides an interactive guide that demonstrates how members can follow the different steps.
UnitedHealthcare adopts this update as part of its healthcare optimization initiative that benefits patients and medical care providers. Members receive quicker care accessibility when providers reduce their practice in unwarranted referrals, while minimizing administrative workloads.
Get in touch with UnitedHealthcare Community Plan if you have any queries about the referral procedure or require further information.
The Centers for Medicare and Medicaid Services (CMS), through their official announcement on April 17, 2025, extended the necessary off-cycle revalidation deadline for skilled nursing facilities (SNFs). The revised deadline demands SNFs to finish their revalidations together with an updated Attachment 1 instead of Form 855A Sections 5 and 6 before August 1, 2025, while the previous deadline was set for May 1, 2025. The extended deadline provides SNFs with more time to finish their revalidation process and sustain their Medicare payment benefits.
Following CMS’s April 9, 2025, sub-regulatory guidance update, further details were provided on SNF Attachment 1 requirements. The guidance clarifies the definition of an additional disclosable party (ADP) and outlines disclosure obligations for therapy service providers under Attachment 1. This update aims to streamline compliance processes for SNFs. CMS encourages facilities to review the guidance thoroughly to ensure accurate submissions.
