Q2 Kickoff: UHC PCP Referral Enforcement Starts May 1
Key billing, coding, and payer policy updates for independent specialty practices — curated for your team and your markets.
NC Medicaid
1 updateWellCare of NC Becomes Carolina Complete Health — What Your Front Desk Needs to Do
WellCare of North Carolina merged into Carolina Complete Health (CCH) on April 1, 2026. Any provider contracted with either WellCare or CCH before April 1 remains contracted and in-network with CCH — no re-credentialing is needed. All patients who were enrolled in WellCare are now CCH members.
The practical issue is at check-in: patients coming in with WellCare cards are still eligible, but the card is now incorrect. Staff should recognize that WellCare Medicaid patients are CCH as of April 1, end-date existing WellCare policy records effective March 31, and enter a new CCH policy effective April 1. For any claims with a date of service on or after April 1, bill to Carolina Complete Health.
All Specialties
4 updatesUHC Medicare Advantage HMO: PCP Referral Now Required Before Specialist Visits — Denials Begin May 1
Since January 1, 2026, most patients enrolled in a UnitedHealthcare Medicare Advantage HMO or HMO-POS plan have been required to obtain a referral from their primary care provider before seeing a specialist. UHC waived claim denials through April 30 to give practices time to build the workflow. Starting May 1, 2026, claims for specialist services without a valid referral on file will be denied — and the financial liability falls on the provider. Patients cannot be balance billed.
The referral must be submitted to UHC by the patient's PCP before the specialist visit — and it must be in the UHC system before the appointment, not retroactively. Referrals are submitted through the UHC Provider Portal. A single referral covers all providers billing under the same tax ID and same specialty, so a practice-level referral number covers multiple providers within the same specialty group. The requirement does not apply to PPO plans, most SNPs, radiology, lab, oncology, mental health/behavioral health, OB/GYN, or routine preventive services. Pain management services rendered by an anesthesiologist do require a referral. Same-day orthopaedic urgent care for acute fractures, sprains, strains, or dislocations is also exempt.
UHC — Excludes 1 Diagnosis Code Policy Now Applies to All Claim Types
Effective March 1, 2026, UHC expanded its Excludes 1 diagnosis code reimbursement policy to cover both outpatient and professional claim types (previously applied only to facility claims). Excludes 1 guidelines identify diagnosis code pairs that represent mutually exclusive conditions — for example, a congenital form and an acquired form of the same condition — and cannot be reported together on the same claim. Claims that include Excludes 1 code combinations will be edited or denied. Staff submitting professional claims should verify that diagnosis code combinations on any UHC claim do not violate Excludes 1 guidelines before submission.
UHC — Radiology Professional Component Not Separately Reimbursable Without Full Written Report
Effective April 1, 2026, UHC will not separately reimburse the professional component (modifier 26) of a radiology service if the reviewing physician did not produce a full written interpretation and report. When this condition is not met, the professional component payment is considered bundled into the associated evaluation and management service. Additionally, when a global radiology code is billed on the same date of service as an E/M for the same patient, the professional component of that global code will not be reimbursed separately unless a copy of the completed radiology report is attached to the claim.
This particularly affects orthopaedic, neurosurgery, and pain management practices that bill in-office imaging alongside E/M visits.
Medicare Telehealth — Key Provisions Made Permanent
The 2026 Medicare Physician Fee Schedule permanently eliminated frequency limits on telehealth services for patients in hospitals and skilled nursing facilities, and made virtual direct supervision permanent for most services that previously required in-person supervision. These provisions had been operating on temporary extensions since the pandemic. Practices that have incorporated telehealth into their care model now have the regulatory certainty to build around these service lines long-term — across all specialties.
Dermatology
2 updatesSkin Substitutes — Medicare Now Pays a Flat $127.28/cm² Regardless of Product
Effective January 1, 2026, Medicare reclassified most skin substitute products from biologicals (billed at ASP+6%) to incident-to supplies. All products now reimburse at a flat national rate of $127.28 per square centimeter, regardless of brand or acquisition cost. The only exception is products licensed as biologicals under Section 351 of the Public Health Service Act — a very small subset of the market that retains the ASP+6% methodology.
WISeR Model: NJ Derm Practices Applying Skin Substitutes for DFU/VLU Must Obtain Prior Authorization
The CMS WISeR (Wasteful and Inappropriate Service Reduction) model, launched January 15, 2026, requires prior authorization or pre-payment review for certain services billed to traditional Medicare in New Jersey, Ohio, Oklahoma, and Texas. For dermatology specifically: skin substitute applications for diabetic foot ulcers and venous leg ulcers are included in the covered service categories.
Providers have two options: submit a prior authorization request before the procedure (if affirmed, valid for 120 days; standard decisions issued in 3 business days) or proceed without authorization and face a post-service pre-payment review. If the post-service review does not affirm the claim, payment is withheld. The WISeR model applies only to traditional Medicare — Medicare Advantage patients, emergency services, and inpatient procedures are not affected. Arizona and Washington were originally in the pilot but are not currently active for skin substitutes due to the December 24 LCD withdrawal.
Orthopaedics
1 updateIn-Office Imaging Billed Same-Day as E/M: Attach the Radiology Report
UHC's April 1 policy change (noted above in All Specialties) is especially relevant for orthopaedic practices that routinely bill in-office X-rays alongside E/M visits. When a global radiology code and an E/M are billed on the same date for the same patient, UHC will not pay the professional component of the imaging separately unless the completed radiology report is attached to the claim. This is a documentation discipline reminder as much as a policy update — the clinical interpretation should be documented in the record and attached at the time of billing.
Pain Management / Neurosurgery
1 updateUHC Radiology PC/TC Policy: Pain and Neuro Practices Billing Imaging Are Affected
Pain management and neurosurgery practices that bill professional reads on imaging (e.g., reviewing MRIs or CT scans in-office and billing modifier 26) are directly affected by the UHC April 1 policy change. Without a complete written interpretation and report, the professional component will be bundled into the E/M and not separately reimbursed. This is consistent with longstanding documentation standards but is now explicitly enforced in UHC's reimbursement policy. Confirm that interpreting physicians are producing full written reports — not just a brief notation in the progress note.
Reminders from Last Month
Items still in effect or approaching effective dates
Medicare Advantage Network Disruptions — Keep Checking Eligibility at Every Visit
Approximately 2.9 million Medicare Advantage patients lost their 2025 plans as UHC, Humana, and Aetna exited counties nationwide. Auto-enrollment happened quickly and many patients are still presenting with outdated insurance cards. A patient on a UHC PPO in December may now be on an Aetna HMO. Run real-time eligibility before every MA patient encounter.
Aetna — Bundled PA Requests for Musculoskeletal Conditions
Aetna announced it is consolidating PA requests for musculoskeletal conditions — X-rays, knee arthroplasty procedures, certain related medications — into a single bundled authorization. Medical and pharmacy PAs are also being combined where both apply. Confirm your team knows the updated submission process for Aetna musculoskeletal cases to avoid submitting duplicate or fragmented requests.
Healthcare Dive →| Payer | Network | Coding | Billing |
|---|---|---|---|
| Medicare | |||
| UHC | |||
| Aetna | |||
| BCBS | |||
| NC Medicaid |