UHC’s New (2025) Modifier Requirements for Participating Providers in Commercial Plans (Template)

Beginning February 1,  2025, UnitedHealthcare (UHC) updated its policies regarding non-covered services, prior notification, and a required -GA modifier. Participating providers must ensure compliance with these protocols to avoid claim denials and potential financial liability. Below is a breakdown of the key policy updates, including the implications for chiropractic services under per-diem reimbursement models.

The ICS strongly believes that doctors should have the ability to provide appropriate care to their patients without unnecessary insurance barriers, especially when it comes to non-covered services. Patients and their doctors should have the freedom to enter into private contracts for care, ensuring that treatment decisions are based on clinical need rather than insurance restrictions.  However, when health plans change provider agreement provisions affecting reimbursement, we believe it is important that you are informed about these important changes.

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UnitedHealthcare (UHC) now requires compliance with this new -GA modifier guideline for providers participating in their network. You will find the announcement regarding the -GA modifier here and the details regarding the requirements and protocol here (pages 139-140).

Billing UHC Insured for Non-Covered Services

Under UHC’s updated guidelines, contracted providers may collect payment from commercial members for services not covered under their benefit plan, but only if they obtain the member’s written consent before providing the service. The consent form must include:

• An estimate of the charges.
• A specific statement indicating the reason why the provider believes the service may not be covered.
• If UHC has determined that a service is not covered, the consent must reflect that determination and confirm the patient agrees to be financially responsible.

Additional UHC Rules for this Protocol:

• Generic, blanket, or blank written consent forms are not acceptable.
• The consent must be specific to the individual service and the reason for the expected denial.
• Providers cannot obtain signatures on blank forms and fill in details later.
• If these requirements are not met, providers cannot bill members for non-covered services.

Required -GA Modifier for Non-Covered Services

To ensure proper adjudication of claims for non-covered services, UHC requires the use of the GA Modifier, but only if the above protocol was followed. According to UHC, “Including the GA modifier on your claim for the non-covered service helps ensure it is adjudicated as member liability where appropriate.”

UHC Medicare Advantage Procedure Requirements

For Medicare Advantage (MA) patients, UHC has additional requirements:

UHC requires written consent from MA patients AND one of the following must be met:

1. The service is clearly excluded in the patient’s plan documents:
   1. If the patient’s Evidence of Coverage (EOC) or plan materials explicitly exclude the service, you do not need a pre-service determination.
   1. Use the GY modifier on the claim to indicate the service is statutorily excluded and bill the patient directly.
2. A pre-service determination:
   1. If you suspect a service may not be covered and it is not explicitly excluded in plan documents, you must request a pre-service organization determination from UHC before providing the service.
   1. If UHC denies coverage, they will issue an Integrated Denial Notice (IDN), which is required before billing the patient.

In either of these cases, providers should append the GA modifier. However, if neither are met, UHC indicates the provider assumes liability for the charges.

Download the UHC written consent form template here.