Quick facts
- Payer: UnitedHealthcare Community Plan (Medicaid managed care)
- Kentucky: three changes on December 1, 2026
- Massachusetts: modifier 78 change on November 1, 2026. Maryland: same change on December 1, 2026
- Wisconsin: multiple-procedure payment reductions on November 1, 2026
- All states: obstetric billing change on January 1, 2027
Kentucky: three changes on December 1, 2026
1Preventive visit + sick visit on the same day
If the same provider does a preventive (wellness) visit and a separate problem visit for the same patient on the same day, the problem visit billed with modifier 25 will be cut by 50%. Pediatric, family medicine and internal medicine practices will feel this most.
What to do: keep billing the problem visit when it's truly separate and significant, document it clearly, and expect half payment. Update your expected-payment tables so the shortfall isn't mistaken for an underpayment.
2Office-only procedures billed in a hospital
Some procedure codes are flagged by CMS as rarely or never done in a facility. If a physician bills one of those codes with place of service 21 (inpatient hospital), UHC won't pay the professional claim. The facility can still be considered for payment.
What to do: check that your place-of-service codes are accurate, especially for hospitalists and surgeons who also see patients in the office.
3"Excludes 1" diagnosis coding rules on every claim
ICD-10 has "Excludes 1" notes, which flag pairs of diagnoses that shouldn't be coded together. UHC will now enforce these on all claim types, including professional claims. Claims that break them may be denied.
What to do: turn on Excludes 1 edits in your claim scrubber and review templates that auto-add diagnosis codes.
Kentucky also gets a home health rule (place of service 12 claims overlapping an inpatient stay won't be paid) and an expanded vitamin D testing policy (see our lab testing guide).
Massachusetts and Maryland: modifier 78 pays less
Modifier 78 is used when a patient has to go back to the operating room during a surgery's global period. UHC currently pays these at a flat 84% of the allowed amount. Starting November 1, 2026 in Massachusetts and December 1, 2026 in Maryland, UHC will pay the CMS intraoperative percentage for each procedure instead, which ranges from about 60% to 84%. For many procedures, that's less.
What to do: surgical practices should look up the CMS intraoperative percentage for their common return-to-OR procedures and update expected payments.
Wisconsin: multiple procedures on the same day pay less
Starting November 1, 2026, UHC Community Plan in Wisconsin follows Medicare-style multiple procedure payment reductions:
- Ultrasound: the second and later ultrasounds for the same patient, same session and same day take a 50% cut to the technical component and a 5% cut to the professional component. This applies even across different physicians in the same group.
- Endoscopy: CMS's endoscopy "family" rules apply, and endoscopy codes may be subject to both the endoscopy and the multiple-procedure reductions.
- Cardiovascular and ophthalmology diagnostic tests: the second and later tests on the same day get a reduced technical component.
What to do: imaging, GI, cardiology and eye practices in Wisconsin should update expected payments so these reductions aren't flagged as underpayments.
All states: obstetric billing changes January 1, 2027
UHC Community Plan is changing how maternity care is reported, and the details depend on what CMS finalizes. If CMS finalizes its proposed maternity G-codes, UHC will use them. If not, UHC will move to phase-based reporting. For services on or after January 1, 2027, use the appropriate E/M codes, because antepartum-only global obstetric codes will no longer apply. Services on or before December 31, 2026 follow 2026 CPT rules.
What to do: OB/GYN practices should flag patients whose pregnancies span the new year. Your prenatal billing may need to be split by date of service.
How HealthRescue Partners can help
We keep claim scrubber rules current with payer bulletins so changes like these are caught before claims go out. See medical billing services (4% of collections), medical coding, women's health and OB/GYN billing, pediatrics, or start with a free billing audit.
Frequently asked questions
Does UHC Community Plan pay for a sick visit on the same day as a preventive visit in Kentucky?
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Yes, but starting December 1, 2026 the E/M billed with modifier 25 is reduced by 50% when the same provider bills it on the same day, for the same patient, as a preventive medicine visit.
How will UHC Community Plan pay modifier 78 in Massachusetts and Maryland?
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Instead of a flat 84% of allowed, procedures with 10- or 90-day global periods billed with modifier 78 will be paid at the CMS intraoperative percentage, roughly 60% to 84%. It starts November 1, 2026 in Massachusetts and December 1, 2026 in Maryland.
What is the Wisconsin ultrasound multiple procedure reduction?
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From November 1, 2026, UHC Community Plan in Wisconsin reduces the technical component by 50% and the professional component by 5% for the second and later ultrasounds for the same patient, session and date.
What is changing in UHC Community Plan obstetric billing in 2027?
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Starting January 1, 2027, maternity care moves either to CMS's maternity G-codes (if CMS finalizes them) or to phase-based reporting. Antepartum-only global obstetric codes will no longer apply.
Sources
This article explains payer and CMS rules in plain language for practice owners. It is not legal advice. Rules can change after publication, so always confirm against the source document before changing how you bill. Last reviewed November 9, 2026.