Reimbursement Policies

The services described in OptumHealth Care Solutions, LLC. Reimbursement Policies are subject to the terms, conditions and limitations of the Member's contract or certificate. OptumHealth Care Solutions, LLC. (OptumHealth) reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by OptumHealth's administrative procedures.

The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.

Please select one of the Reimbursement Policies presented below.
0044 Physical and Occupational Therapy Evaluation Reimbursement Policy This policy describes the methodology and consideration for reimbursement of CPT codes 97001 and 97003 (Physical Therapy Evaluation and Occupational Therapy Evaluation).
0045 Chiropractic Manipulative Treatment Reimbursement Policy This policy describes the methodology and requirements for reimbursement of CPT codes 98940, 98941, 98942, and 98943.
0046 Hot and Cold Pack Reimbursement Policy This policy describes OptumHealth methodology and requirements for reimbursement of CPT code 97010 (Application of a modality to one or more areas; hot or cold packs).
0047 Unattended Electrical Stimulation Reimbursement Policy This policy describes OptumHealth methodology and requirements for reimbursement of CPT code 97014 (Application of a modality to one or more areas; electrical stimulation [unattended]).
0048 Timed Therapeutic Intervention Reimbursement Policy This policy describes OptumHealth reimbursement for timed therapeutic services (CPT codes 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762).
0049 Documentation Requirements for Reimbursement of Timed Therapeutic Procedures This policy describes reimbursement of the Physical Medicine and Rehabilitation (PM&R) CPT codes which make up the timed, skilled, direct one-on-one component of treatment. Specifically CPT codes, 97110-97140, 97530-97542, 97750-97762.
0050 Modifier 59 Reimbursement Policy This policy describes OptumHealth methodology and requirements for the reimbursement of CPT codes appended by modifier -59.
0050 Modifier AT Reimbursement Policy This policy describes OptumHealth methodology and requirements for the reimbursement of services appended by modifier -AT.
0050 Modifier 51 Reimbursement Policy This policy describes OptumHealth methodology and requirements for the reimbursement of CPT codes appended by modifier -51.
0050 Modifier 52 Reimbursement Policy This policy describes OptumHealth methodology and requirements for the reimbursement of CPT codes appended by modifier -52.
0050 Modifier 25 Policy This policy describes OptumHealth methodology and requirements for the reimbursement of evaluation and management (E/M) service CPT codes appended by modifier -25.
0050 Modifier GZ Policy This policy describes OptumHealth methodology and requirements for the reimbursement of services appended by modifier -GZ.
0050 Modifier GA Policy This policy describes OptumHealth methodology and requirements for the reimbursement of services appended by modifier -GA.
0051 Physical and Occupational Therapy Reevaluation Reimbursement Policy This policy describes the methodology and consideration for reimbursement of CPT codes 97002 and 97004.
0053 ICD Reimbursement Policy This policy describes provider use of standard code set, ICD (The International Classification of Diseases).
0056 Documentation Requirements for Reimbursement of Evaluation Management (E/M) Services (99201-99205 and 99212-99215) This Guideline describes requirements for reimbursement of the Evaluation and Management (E/M) CPT codes. Specifically new patient CPT codes, 99201-99205 and established patient CPT codes, 99212-99215.
0056 Evaluation Management (E/M) Services Quick Reference Table This document contains an Evaluation Management (E/M) Services Quick Reference Table.
0059 Mutually Exclusive Procedures Policy This policy describes OptumHealth methodology and consideration for reimbursement of mutually exclusive procedures.
0061 Specialty Specific Modifier Policy This policy describes our requirements for physical therapy, occupational therapy, and speech therapy multi-specialty services billed on a single date of service.
0062 Outpatient Consultation Services Reimbursement Policy This policy describes OptumHealth documentation requirements for reimbursement of the Outpatient Consultation CPT codes, 99241-99245.
0064 Obesity Screening and Counseling Reimbursement Policy This policy describes Optumhealth methodology and requirements for the reimbursement of obesity screening and counseling.
0066 Smoking Cessation Counseling Reimbursement Policy This policy describes OptumHealth methodology and requirements for the reimbursement of smoking cessation services.
0068 Multiple Therapy Procedure Reduction (MTPR) Reimbursement Policy This policy describes OptumHealth reimbursement of multiple therapy procedures.