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    v1.0.31
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAmeriHealth Caritas MUE Policy Update | OpenPayer
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    CurrentAmeriHealth Caritas VIP CarePolicy RPC.0024.FLDS

    Medically Unlikely Edits (MUEs)

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    This policy governs claim payment edits for health care services and supplies billed by contracted providers on CMS-1500 or UB-04 forms, or their electronic equivalents. It applies CMS Medicare NCCI MUE daily maximum units and explains how excess units, modifiers, clean claims, and prior authorization affect reimbursement.

    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyMedically Unlikely Edits (MUEs)
    Policy CodePolicy RPC.0024.FLDS
    Change TypeMaterial reimbursement clarification
    Effective DateNot specified
    Last ReviewOct 1, 2025
    Next Review DateDec 1, 202616d
    Key ActionDo not rely on prior authorization to obtain reimbursement above the applicable MUE threshold.
    SourceLink
    POLICY UPDATE CHANGES

    Prior authorization does not permit payment above the applicable MUE threshold.

    Minor formatting and syntax updates were made.

    The policy preamble was revised.

    1 unitExample MUE threshold
    Same dateEvaluation timing
    Same providerProvider aggregation

    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.

    Denied
    Excess units
    No overridePrior authorization

    MUE Reimbursement Criteria

    MUE Reimbursement Criteria

    Payment is subject to the CMS Medicare NCCI MUE daily maximum and related claim-processing requirements.

    ALL of the following

    • The service or supply is reported with a CPT or HCPCS procedure code.
    • The reported units are evaluated for the same date of service and same provider.
    • Units above the applicable MUE value on a single claim line are denied.

      Excess units are not reimbursed.

    • Appropriate modifiers may support consideration of the same procedure code on multiple claim lines when the circumstances warrant separate payment consideration.
    • Prior authorization does not allow reimbursement above the MUE threshold.

      Claims are reimbursed according to the applicable MUE threshold regardless of prior authorization.

    Coding and Unit Limits

    Procedure and supply codes subject to MUE reviewmixed
    No codes listed
    Claim coding terminology referenced by the policymixed
    No codes listed
    MUE maximum units
    What it isThe maximum units of service allowed for a CPT/HCPCS-coded service or supply.
    Date appliedThe limit applies on the same date of service.
    Provider contextThe limit applies when the service or supply is furnished by the same provider.
    Claim-line excess-unit rule
    Edit typeMedicare MUEs are claim-line edits.
    Excess unitsWhen units on a single claim line exceed the procedure code's MUE value, the excess units are denied.

    Provider Billing Actions

    Billing Rule

    Submit Clean Claims

    Submit clean claims to support accurate reimbursement of covered services and supplies.

    Billing Rule

    Report Modifiers Appropriately

    Use appropriate modifier(s) when the same CPT/HCPCS procedure code appears on multiple claim lines and the circumstances support separate consideration for payment. See Reimbursement Policy RPC.0013.FLDS regarding duplicate claims.

    Denial Risk

    Prior Authorization Does Not Override MUE

    Key MUE Definitions

    Medically Unlikely Edit (MUE)
    DefinitionAn MUE is the maximum units of service allowed for the same service or supply represented by a CPT/HCPCS procedure code.
    Date of serviceThe maximum is evaluated on the same date of service.
    ProviderThe maximum applies when the service or supply is furnished by the same provider.
    Same individual physician or other qualified health care professional
    ProfessionalA physician or other qualified health care professional.
    Practice and specialtyThe professional is from the same group practice and has the same specialty and subspecialty.
    Policy Summary
    PayerAmeriHealth Caritas VIP Care
    PolicyMedically Unlikely Edits (MUEs)
    Policy CodePolicy RPC.0024.FLDS
    Change TypeMaterial reimbursement clarification
    Effective DateNot specified
    Last ReviewOct 1, 2025
    Next Review DateDec 1, 202616d
    Key ActionDo not rely on prior authorization to obtain reimbursement above the applicable MUE threshold.
    SourceLink
    On This Page
    MUE Reimbursement CriteriaCoding and Unit LimitsProvider Billing ActionsKey MUE Definitions
    Example
    A procedure code with an MUE value of 1 has a maximum of one unit per date of service by the same provider.

    Prior authorization does not override the applicable MUE threshold. Claims will be reimbursed according to the MUE threshold regardless of prior authorization.

    Note

    Use Coding Reference Materials

    Use current coding reference materials to verify procedure codes, modifiers, MUEs, and correct coding requirements.

    • CPT manuals and associated publications and services for complete descriptions of procedure codes and modifiers.
    • CMS Medicare NCCI edit files for MUEs assigned to CPT/HCPCS procedure codes.
    • Medicare NCCI manuals for correct coding policies.
    • CMS National Correct Coding Initiative (NCCI) resources: https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci
    • See Reimbursement Policies RPC.0023.FLDS for maximum units of service and RPC.0025.FLDS for frequency of services and supplies.
    Tax identification
    The professional reports under the same Federal Tax Identification Number (TIN).
    Same provider
    Group practiceThe physician or other qualified health care professional is from the same group practice.
    SpecialtyThe professional has the same specialty.
    Tax Identification NumberThe professional has the same Tax Identification Number (TIN); these conditions mean the professional is considered the same provider for MUE purposes.