Reimbursement Policy Maximum Units Per Day
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Governance of reimbursement when providers bill multiple units of a procedure or service for a single member on a single date of service; applies to providers billing Amerigroup under the listed Medicaid programs.
No material clinical or coverage changes in this revision.
Daily Unit Reimbursement Rules
Daily unit reimbursement criteria
Reimbursement rules for units billed on the same date of service:
Billing Codes and Unit Limits
| CPT/HCPCS | Services should be billed with appropriate CPT, HCPCS, and/or revenue codes and supported in the medical record. |
Documentation, Exceptions, and Billing Guidance
Document excess units and submit exceptions for consideration
When billed units for a procedure or service exceed the plan's assigned maximum units per day, the units in excess are not eligible for reimbursement. If a provider appropriately bills units that exceed the maximum, the provider must submit supporting documentation for consideration of reimbursement. Maximum units per day are assigned based on claims data analysis. Note that maximum units per day edits do not override National Correct Coding Initiative (NCCI) edits and policy may be superseded by provider, state, federal, or CMS contracts or requirements.
- Excess units billed beyond the assigned per-day maximum are ineligible for payment.
- Providers who bill appropriately for units exceeding the daily maximum must provide documentation for consideration of reimbursement.
- Maximum units per day are determined based on claims data analysis.
- NCCI edits still apply and may affect reimbursement; follow authorization and medical necessity requirements and any overriding contractual mandates.
Key Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.