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New radiology and cardiology prior authorization codes
UnitedHealthcare is adding new CPT codes to their radiology and cardiology prior authorization programs effective April 1, 2026. This includes 5 radiology codes for advanced brain imaging and nuclear cardiology, plus 8 cardiology codes for leadless pacemaker procedures.
By April 1, 2026: Billing team must update prior authorization systems to require approval for CPT codes 70472, 70473, 0865T, 0866T, 0742T, 0795T, 0796T, 0797T, 0801T, 0802T, 0803T, 33274, 0823T, and 0825T for all UnitedHealthcare commercial, Community, Individual Exchange, and Rocky Mountain Health Plans. Update encounter forms and EMR templates to alert providers. Note: Oxford Health Plans exempt from cardiology codes. Claims will be denied without prior authorization.
New genetic and molecular codes announced for prior authorization
UnitedHealthcare will require prior authorization for new genetic and molecular testing code 0605U starting April 1, 2026. This affects commercial and Individual Exchange plans nationwide and aligns with existing prior authorization requirements for genetic testing.
Before April 1, 2026: Billing team must update system to require prior authorization for code 0605U genetic and molecular testing. Update encounter forms and EMR templates to alert providers. Submit prior authorization requests through UnitedHealthcare Provider Portal before date of service. Claims will be denied without prior authorization and providers cannot balance bill members.
Improved prior authorization process for sacroiliac joint injections
Beginning April 1, 2026, UnitedHealthcare will eliminate medical necessity reviews for sacroiliac joint injection prior authorizations (CPT 27096 and HCPCS G0260), but will still require prior authorization with site-of-service reviews. For Kentucky and North Carolina Community Plans, CPT 27096 will no longer require prior authorization at all.
Before April 1, 2026: Billing team must update prior authorization workflows for CPT 27096 and HCPCS G0260 to remove medical necessity documentation requirements but maintain site-of-service reviews for UnitedHealthcare Commercial and Individual Exchange plans. For UnitedHealthcare Community Plans in Kentucky and North Carolina, remove all prior authorization requirements for CPT 27096. Update billing system flags and staff training materials accordingly.
Medicare: New non-formulary medication request process
Starting January 1, 2026, Medicare non-formulary medication requests must include progress notes when patients cannot be switched to formulary alternatives. UnitedHealthcare strongly encourages prescribing formulary medications to avoid delays and denials.
By January 1, 2026: Providers must include progress notes and comprehensive documentation (medical records showing prior medications tried and failed, clinical rationale for requested medication, relevant clinical details like labs and treatment history) for all Medicare non-formulary medication requests when formulary alternatives are not appropriate. Update EMR templates to prompt for this documentation. Failure to include required documentation may result in delays and denials.
New DME process for select members in multiple states
Beginning June 1, 2026, Synapse Health will manage DME ordering and fulfillment for UnitedHealthcare Medicare Advantage plans in multiple states. DME prescribers must use the Synapse Health e-prescribing portal, and DME providers must join the Synapse Health network to continue serving these patients.
By June 1, 2026: Providers in affected states must transition DME prescriptions to the Synapse Health e-prescribing portal for UnitedHealthcare Medicare Advantage patients. Contact Synapse Health at 888-336-9363 for training and portal access. Update workflows to identify which patients require the new Synapse ordering process based on their specific plan type and state. DME suppliers must join the Synapse Health network by emailing JoinOurNetwork@synapsehealth.com or risk losing UnitedHealthcare Medicare Advantage patients.
Review the 2026 Administrative Guide
UnitedHealthcare has released the 2026 Provider Administrative Guide with key updates including removal of prior authorization requirements for several radiology and cardiology services, updated timely filing requirements for corrected claims, and new discharge notification expectations.
By April 1, 2026: Billing team must review the complete 2026 UnitedHealthcare Provider Administrative Guide to identify specific radiology and cardiology services no longer requiring prior authorization. Update billing system rules to remove prior auth requirements for affected services. Review and update corrected claims filing procedures per Chapter 10 changes. Clinical staff should review updated discharge notification requirements in Chapter 7.
North Carolina Medicaid: State upholds EVV transmission requirements
North Carolina Medicaid home health providers must complete dual submissions for encounter visits: transmit EVV data to HHAeXchange AND submit claims to UnitedHealthcare. EVV service codes must exactly match prior authorization and claim submissions, and providers must use taxonomy code 251E00000X or claims will be denied.
Immediately: Home health billing team must implement dual submission process - transmit EVV data to HHAeXchange AND submit claims to UnitedHealthcare for every encounter. Verify EVV service codes exactly match prior authorization approvals and claims. Update billing system to require taxonomy code 251E00000X for all home health claims. Use UnitedHealthcare Community Plan crosswalk for appropriate service type, revenue code and HCPCS/CPT codes. Monitor HHAeXchange import status and resolve failures promptly. Claims using incorrect taxonomy codes will be denied.
New Mexico Medicaid: Updates to gross receipt taxes reimbursement information
Effective January 1, 2026, New Mexico Senate Bill 249 requires UnitedHealthcare to reimburse healthcare providers for gross receipt taxes (GRT) they pay to the state for Medicaid services. Provider remittance advice notices will now show GRT and service payments as separate, itemized lines.
By January 1, 2026: Billing team must review remittance advice notices from UnitedHealthcare to identify separate GRT and service payment line items. Update accounting procedures to properly record and reconcile these separate payments. Consult page 72 of the New Mexico 2026 Turquoise Care Provider Manual for specific GRT rate information.
New Jersey Medicaid: Billing guidance for sickle cell disease treatments
New Jersey Medicaid now participates in the Cell and Gene Therapy (CGT) Access Model, providing Medicaid enrollees with sickle cell disease access to cell and gene therapies at reduced costs. Providers must follow new billing guidance for sickle cell disease gene therapies including specific prior authorization requirements and claim submission procedures.
Immediately: Billing team must review the 'Billing guidance for Sickle Cell Disease (SCD) gene therapies' document to understand new provider requirements, applicable drugs for treatment, prior authorization requirements, and claim submission procedures for New Jersey Medicaid patients with sickle cell disease. Update billing workflows to ensure compliance with CGT Access Model requirements.
Nebraska Medicaid: Knee injection coverage and attestation for single-dose drugs
Effective January 1, 2026, Nebraska Medicaid will discontinue coverage for all hyaluronan knee injections for osteoarthritis and require providers to attest no-waste drug use with modifier JZ for single-dose medications. Ten specific HCPCS codes for knee injections will no longer be reimbursed.
By January 1, 2026: Billing team must update system to deny/flag HCPCS codes J7320, J7321, J7322, J7324, J7325, J7326, J7327, J7329, J7331, J7332 for Nebraska Medicaid patients as non-covered. Add modifier JZ to all single-dose drug claims for Nebraska Medicaid. Providers must document any drug wastage in medical records. Update encounter forms and billing software rules. Claims without proper attestation or for discontinued codes will be denied.