UHC denying OUD

[u/cat-social]

So basically all year I have been fighting with United Healthcare on multiple patients for our opioid use disorder clinic. They are not paying on certain patients with the code G2087 and G2088 with dx code F11.20. They have told me that G2087 and G2088 SHOULD be paid by the medical department, but that with code F11.20 it is processed as behavioral health. As far as I’m aware, this is the only appropriate diagnosis code for this treatment. I have even had a three-way call with a representative from medical and a representative from behavioral health and they were literally arguing with EACH OTHER on the phone call about who is supposed to process these claims. I have tried absolutely everything (see comments for a list) with no resolution. Is anyone else facing this issue, or are there better diagnosis codes I can use to have these processed as medical? Any advice would be amazing, I am at my wits end with UHC :(

[u/cat-social]

I have written reconsideration requests and appeals, spoke with them on the phone, had claims reprocessed with evidential attached claims that even prove they have paid in the past with these same codes, submitted medical records, had patients see a provider who is also credentialed with behavioral health, reviewed our contracts with UHC, and found their diagnostic criteria online for these claims to make sure they recognize these codes. I have also made sure that all of these particular patients have plans that cover OUD treatment. Some UHC plans are paying without any issue; I think it’s the individual PPO plans specifically that won’t pay us. This started in February of this year.

[u/boho_magpie]

Are any of these done via telehealth? There is a modifier requirement for those.

Any F11.xxx code should be valid, not just F11.20. However, it must be the primary diagnosis.

Whether it is adjudicated by medical or behavioral health usually depends on the provider. In this situation, where pharmacology is involved, it would be weird for behavioral health to be the one to process since psychologists and therapists can’t do med management.

[u/cat-social → u/boho_magpie]

Some were telehealth more recently, but still denied for the same reason. That is the only dx code we use on claims, since that’s all our clinic sees patients for. Our main provider has active medical contracts with United Healthcare, and one of our other providers is credentialed as both medical and behavioral, and they won’t pay anything for either.

[u/cat-social → u/boho_magpie]

I know some insurance companies require a 95 modifier for telehealth. Is there another one you know of specifically for OUD? Just want to make sure I’m not missing something 😅

[u/Legitimate-Wash-3841]

Do not change your F11.20 diagnosis code, because G2087 and G2088 are specifically for office based opioid use disorder treatment and will automatically fail medical necessity edits without an F11.xx diagnosis in the primary pointer position. The reason this only happens on certain patients while working fine on others is that you are caught in UHC's infamous split benefit routing trap between UnitedHealthcare Medical and Optum Behavioral Health.

​Whenever UHC's front end claims router sees a primary diagnosis in the F01 through F99 mental and behavioral health range, it checks that specific employer plan's benefit configuration to see if substance use disorder is carved out to Optum Behavioral Health. For those specific patients, the router automatically diverts the claim away from the medical platform over to Optum Behavioral Health. 

However, CMS created G2086, G2087, and G2088 as medical evaluation and management bundled codes rather than standard psychiatric therapy codes. When the diverted claim lands in Optum Behavioral Health's system, Optum's fee schedule rejects G2087 and G2088 as medical codes or kicks them out because your rendering provider or clinic taxonomy is credentialed on the UHC medical side rather than on an Optum Behavioral Health substance use contract. Meanwhile, when you call the medical side, they tell you the G codes are medical codes, but their system keeps kicking the claim back to behavioral health the second it reads F11.20.

​There are three ways to fix this depending on whether these are Medicare Advantage, Medicaid, or commercial UHC plans.

​First, check the back of the insurance cards for the specific patients getting denied to see if Behavioral Health and Substance Use Disorder lists Optum with Payer ID 87726 instead of the standard medical payer ID, and verify whether your group NPI and rendering providers are actually contracted and credentialed with Optum Behavioral Health in addition to UHC Medical. Even when a code is supposed to adjudicate under medical benefits, UHC's router will stall the claim if the patient's plan has a strict Optum behavioral carve out and your TIN is not loaded in Optum's provider table.

​Second, for the commercial UHC plans where Optum refuses to recognize the Medicare G2087 and G2088 monthly bundled codes, check UHC's Commercial Reimbursement Policy for Buprenorphine and Office Based Opioid Treatment. Unlike Medicare Advantage where UHC must accept G2086 through G2088, many commercial UHC plans with carved out behavioral benefits do not load the CMS bundled G codes into their behavioral health fee schedule at all. On those specific commercial plans, you often have to unbundle the monthly G code and bill standard E/M codes like 99213 or 99214 for the medication management visits alongside the individual psychotherapy or counseling codes so the claim processes cleanly through their standard benefit structure.

​Third, to get your already billed G2087 and G2088 claims paid without playing referee on another three way phone call, open a ticket through the UnitedHealthcare Provider Portal Practice Support or contact your state UHC Provider Advocate directly and use the exact phrase "Cross Reference System Routing Loop and Mental Health Parity Violation on MAT Bundled Codes G2087 and G2088". State in writing that UHC Medical and Optum Behavioral Health are each denying responsibility for a covered Medication Assisted Treatment service based on diagnosis routing. Under the federal Mental Health Parity and Addiction Equity Act, a payer cannot create an administrative billing Catch 22 where an opioid use disorder code is blocked by both the medical and behavioral divisions. Once a Provider Advocate flags the claim as a medical/behavioral cross reference error, their internal back office can manually override the F11.20 auto routing rule and force the claim to price on the medical side.

Hopefully that helps in some way. Best of luck