For Providers of UnitedHealthcare Community Plan in New York
Important Notice: When submitting claims for prenatal or postpartum services, include a Category II CPT code alongside global or bundled billing codes. Use one of these Category II codes as appropriate:
Purpose of Category II CPT Codes
Incorporating Category II CPT codes in your claims supports adherence to the prenatal and
postpartum care standards set by the New York State Department of Health.
How to Submit a Claim
Claims can be submitted via the UnitedHealthcare Provider Portal:
Additional Resources
Starting January 1, 2025, the criteria for follow-up after emergency department visits for mental health (FUM) will expand to include additional diagnoses, potentially requiring members to schedule follow-up appointments. Members seen in the emergency department for substance use (FUA) will also need follow-up care.
Both medical and behavioral health care providers can utilize appropriate billing and diagnostic codes to address the FUM and FUA HEDIS® gaps.
How providers can assist:
Healthcare providers serve as essential connectors between care services. They schedule follow-up appointments for patients who receive emergency department discharge for mental health or substance use issues within 7 days. The first day after hospital discharge serves as Day 1 for counting purposes. When a visit within seven days is not feasible, the patient should receive a follow-up appointment within 30 days.
The correct billing codes should be used by providers to address FUM and FUA HEDIS gaps. Both medical and mental health providers can use these codes to improve care gaps, but the codes should not guide billing practices.
FUM: Outpatient behavioral health visits for any mental health disorder diagnosis:
98960, 98961, 98962, 99078, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99483, 99492, 99493, 99494, 99510
FUM: Outpatient visit with any mental health disorder diagnosis and the correct place of service code:
90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99252, 99253, 99254, 99255
FUA: The correct place of service code must accompany outpatient visits that diagnose substance use disorder or drug overdose or mental health provider appointments:
90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90847, 90849, 90853, 90875, 90876, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99252, 99253, 99254, 99255
FUA: A behavioral health visit that includes any substance use disorder diagnosis or, drug overdose diagnosis, or a mental health provider visit requires FUA status:
98960, 98961, 98962, 99078, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99483, 99492, 99493, 99494, 99510
The place of service and additional codes for this measure, along with others, can be found in the PATH reference guide.
Contact the behavioral health number listed on the member ID card's back to obtain a network behavioral health professional referral for additional assessment or treatment.
Resources
View more information and resources on UHC Provider’s Clinical Tool page or on the Optum Provider and Staff Toolkits page.
Medicare provider enrollment policies received substantial revisions from the Centers for Medicare & Medicaid Services (CMS) during this spring season, which both reinforced established requirements and added new clarification methods to minimize enrollment challenges and waiting times.
The April 3, 2025, MLN newsletter published by CMS reaffirmed the need for providers to report “managing employees” during enrollment to prevent deactivation. The healthcare organization relies on managing employees to perform CEO and CFO tasks as well as the roles of Clinical Manager, Compliance Officer, and others who maintain operational control (MLN, 2025).
CMS made additions to Chapter 10 of the Medicare Program Integrity Manual through Transmittal 13062 beginning on April 11, 2025. The guidance requires that legal business names present identical information within all IRS CP-575 documents and PECOS and NPPES systems. The Medicare Administrative Contractor (MAC) has the authority to approve minor discrepancies, such as punctuation and commonly used word differences, when supporting documentation verifies provider identity (CMS, Transmittal 13062, 2025).
Medicare Administrative Contractors can accept one legal name variation through special characters and punctuation, along with minor wording differences of common words like “the,” “of,” or “and.” Any mismatch between legal business names needs proper documentation that proves its justification when the limits are not exceeded.
CMS explicitly stated that the street address on CMS-588 EFT Forms may display any applicable provider location from practice sites or chain home offices. Suppliers who participate in MAC jurisdictions need not resubmit their CMS-460 form but must present an original copy of it.
The new Part A/B Approval Letter Templates establish that CMS-approved Accreditation Organizations should submit their recommendations for state agency final certification (CMS, 2025).
The system updates are designed to automate provider enrollment procedures while minimizing processing interruptions.
The updated guidelines for the Follow-Up After Emergency Department Visit for Mental Illness (FUM) measure will expand the included mental health diagnosis criteria starting January 1, 2025. The expanded FUM measure will cause more patients to need clinical follow-up after emergency room treatment. Healthcare providers should schedule timely follow-up appointments for substance use disorder patients according to the FUA measure.
Medical and behavioral health providers should use qualified billing and diagnostic codes during follow-up appointments to support healthcare providers in closing HEDIS® gap measures. The follow-up appointment for patients must occur within seven days after ED discharge, where day one starts the day following their ED release. A follow-up appointment scheduled in the first 30 days after discharge will fulfill the requirements for quality measure adherence when a 7-day appointment is not possible.
Medical practitioners have access to multiple suitable billing codes, such as CPT 99202 through 99215, along with 99381–99397 and 99401–99404, and 90791–90876.
FUM: CPT codes such as 99202–99215, 99381–99397, 99401–99404, and psychiatric-specific codes like 90791–90876.
The same set of billing codes applies to FUA, but substance use disorder or overdose diagnoses should be prioritized in the diagnosis section.
Only encounters that match their assigned place-of-service codes can qualify for validity. The updates function as guidance tools to enhance quality care while avoiding any mandate for billing procedures.
The PATH reference guide and other resources assist providers in meeting requirements for HEDIS® reporting. When making network referrals, providers must reach out to the behavioral health number that appears on the member ID card of their patients.
Professional information exists on both the Clinical Tool page and the Optum Provider and Staff Toolkits. Any questions can be asked through a real-time chat service that runs 24 hours a day through the UnitedHealthcare Provider Portal.
Ohio established a new claims submission policy starting May 1, 2025, that mandates all Ordering Referring and Prescribing (ORP) health care professionals to possess a valid National Provider Identifier (NPI). UnitedHealthcare Community Plan of Ohio has stated that they will deny claims that lack an NPI number for ordering, referring, and prescribing professionals as per the new state policy.
The updated requirement supports state initiatives to improve Medicaid billing transparency by requiring NPI numbers. The Y42 denial code accompanies claims that do not fulfill this requirement through one of the following messages.
Any health care provider receiving a Y42 denial should correct their claim with the correct NPI number. Make sure it is a timely filing deadline specified in their UnitedHealthcare Provider Agreement. The denial will become permanent when claims are submitted past their deadline.
This policy change will mostly impact behavioral health services, together with other Medicaid-covered treatments that need ORP professional intervention.
Healthcare providers should access UnitedHealthcare's documentation on claim correction guidelines and view the procedures requiring NPI numbers for ORP professionals. Further information and guidance for UnitedHealthcare services exist under the “Contact Us” section of their website.
Health care professionals, together with billing administrators, must take immediate action to validate that their systems and teams comply with the upcoming May 1 deadline.
Additional details, together with current information, can be found on UHC provider resources available at uhcprovider.com.
The Texas Medicaid & Healthcare Partnership (TMHP) adopted the first quarter of 2025 Healthcare Common Procedure Coding System (HCPCS) updates starting with April 1, 2025 dates of service on March 27, 2025. The procedure code updates present new entries and noncovered codes as well as age restrictions and necessary prior authorizations and eliminated codes.
Newly Added Procedure Codes
TMHP added the CAD procedure codes C9302 and J0281 and J1072 and J1271 and J1299 and J1308 together with other new codes to their system. The procedures will receive coverage under Texas Medicaid starting April 1, 2025. The rates must be implemented before claims denial until the reprocessing of impacted claims will commence.
Through the HTW program J1271 became an added benefit to the available benefits.
| Clinician-Administered Drug (CAD) Procedure Codes | ||
| C9302 | C9303 | C9304 |
| J0281 | J1072 | J1271 |
| J1299 | J1308 | J1808 |
| J1938 | J2351 | J2804 |
| J2865 | J9024 | J9054 |
| Q2057 | Q5147 | |
Texas Medicaid will cease coverage of C9300, J2428, J7521, A2030-A2035, E0201, E1032, G0566 and other codes as of April 1, 2025.
| CAD Procedure Codes | ||
| C9300 | C9301 | J2428 |
| J7521 | J9038 | J9161 |
| Q5148 | Q5149 | Q5150 |
| Q5151 | Q5152 | Q9999 |
| Non-CAD Procedure Codes | ||
| A2030 | A2031 | A2032 |
| A2033 | A2034 | A2035 |
| A6515* | A6516* | A6517* |
| A6518* | A6519* | A6611* |
| A9154 | A9611 | C8004 |
| C8005 | E0201 | E1022* |
| E1023 | E1032* | E1033* |
| E1034* | E1832* | G0183 |
| G0566 | G0567 | L0720* |
| L1933* | L1952* | L5827 |
| L6028* | L6029* | L6030* |
| L6031* | L6032* | L6033* |
| L6037* | L6700 | L7406 |
| Q4354 | Q4355 | Q4356 |
| Q4357 | Q4358 | Q4359 |
| Q4360 | Q4361 | Q4362 |
| Q4363 | Q4364 | Q4365 |
| Q4366 | Q4367 | S4024 |
The Texas Medicaid rate hearing process will be necessary to approve specific codes that have an asterisk (*) mark.
| Diagnosis Codes | ||
| C155 | C158 | C159 |
| C160 | C161 | C162 |
| C163 | C164 | C165 |
| C166 | C168 | C169 |
| Procedure Codes | ||
| L6028 | L6029 | L6030 |
| L6031 | L6032 | L6033 |
| L6037 | ||
Procedure codes J9054 and C9304 and J2351 require age-based limitations for patients under 24 months and those above 18 years. The procedure codes E1022, L0720, L6028 and J1072 need authorization before scheduling the appointment.
| Procedure Codes | ||
| 99232 | A4453 | |
| A6549 | A6583 | |
| A6586 | A6587 | |
| C1739 | C9793 | |
| E1028 | E1801 | |
| E1816 | E1818 | |
| J9073 | L1932 | |
| L1971 | L6692 | |
| S4020 | S4021 | |
| Procedure Codes | ||
| 0531U | 0532U | 0533U |
| 0534U | 0535U | 0536U |
| 0537U | 0538U | 0539U |
| 0540U | 0541U | 0542U |
| 0543U | 0544U | 0545U |
| 0546U | 0547U | 0548U |
| 0549U | 0550U | 0551U |
The procedure codes A9155, G0564 J1094, and S4988 will cease to exist starting March 31, 2025. The description of procedure codes 99232 A4453 and L1971 will experience changes.
Discontinued Procedure Codes
| Procedure Codes | ||
| A9155 | G0564 | G0565 |
| J1094 | J1300 | J1810 |
| J1890 | J1940 | J9037 |
| J9247 | L8010 | Q4231 |
| Q5139 | S0017 | S0028 |
| S0032 | S0039 | S4988 |
For full details, visit TMHP or call the TMHP Contact Center at 800-925-9126.
The Texas Health and Human Services Commission published the Texas Medicaid Excluded Providers List for March 2025 production. The updated list is available for healthcare providers along with stakeholders to verify Medicaid compliance by excluding entities from their operations.
Texas Medicaid program participants need the exclusion list as their essential tool to identify prohibited entities that violate program requirements by committing acts of fraud or abuse. Medical providers together with entities need to perform routine examinations of the exclusion list to verify they do not work with sanctioned individuals or entities.
The HHSC Office of Inspector General (OIG) website provides the Texas Medicaid exclusion list at oig.hhsc.texas.gov/exclusions. Texas Medicaid Excluded Providers section maintains recent updates about providers barred from participating on the state’s official Medicaid website.
Individuals need to dial 800-436-6184 for the Texas Medicaid Fraud and Abuse Hotline to report suspected provider Medicare fraud and abuse activities. The hotline functions as an anonymous reporting facility through which people can disclose fraudulent activities that affect the Medicaid program.
The Texas Medicaid Excluded Providers List receives its monthly update on the last Monday of each month. Every month all healthcare organizations and providers should check the list to prevent liability costs that arise from working with excluded providers.
On May 1 2025 TurningPoint Healthcare Solutions, LLC (TurningPoint) will manage the duty of handling inpatient and outpatient musculoskeletal surgical procedure prior authorization requests for UnitedHealthcare commercial plan members throughout Florida. The change initiative applies to UnitedHealthcare commercial plan members through ASO plans together with fully funded options. No new prerequisite authorizations are implemented as part of this change.
The clinical reviews conducted by TurningPoint follow all UnitedHealthcare clinical policies as their foundation. The medical professionals must be certified in the appropriate field of subspecialty to maintain adherence to current guidelines during their review processes.
Training and Registration
Providers can access training from TurningPoint regarding the program's overview and portal utilization along with related resources. Training sessions require provider registration as a means to achieve a smooth transition process.
Plans Exempt from This Requirement
This change does not apply to the following plans:
Submission Process and Key Dates
The TurningPoint portal demands provider prior authorization submission starting from April 21, 2025, to represent services starting May 1, 2025, and beyond. Healthcare providers should continue sending their procedure requests to UnitedHealthcare which pertains to requests scheduled before May 1, 2025. The UnitedHealthcare Provider Portal sends requests to TurningPoint but users should submit directly to TurningPoint for faster handling.
Contact Information
For assistance, providers can contact TurningPoint via:
Phone: 904-895-4007
Fax: 904-544-8025
Per the New Jersey Administrative Codes, prior authorization is mandatory for all Personal Care Assistance (PCA) services. These services are reviewed based on a written plan of care documenting the member’s certification of need for personal, hands-on care. A registered professional nurse uses the state-approved PCA Assessment Tool to determine the number of PCA hours required per calendar week.
Important: Unused PCA hours cannot be carried over or used on a later date, even in cases of:
Example:
A member is approved for 30 hours of PCA services per week.
Billing for unused hours in a subsequent week is considered noncompliance with New Jersey Medicaid regulations.
Texas Medicaid introduced new requirements for state-mandated medication prior authorization procedures. New prior authorization requirements will begin on May 1, 2025 while specific medication clinical criteria will receive updates at that time. The new changes affect UnitedHealthcare Community Plan of Texas CHIP, STAR, STAR Kids and STAR+PLUS health plans.
| Clinical Criteria Guidelines | Medication | Clinical Criteria Updates |
| Monoclonal Antibody Agents | Tezspire® (tezepelumab-ekko) | Criteria added for Tezspire |
| Ebglyss™ (lebrikizumab-lbkz) | Criteria added for Ebglyss, approved by the Drug Utilization Review Board |
So, this material should assist you in deciding whether you will have to submit a prior authorization request or instead just make a note of the clinical criteria before ordering any of these medications.
