CurrentAnthemPolicy G-15003

Maximum Units Per Day reimbursement policy

Governs reimbursement when providers bill multiple units of the same procedure/service for a single member on a single date of service; applies to Anthem Blue Cross and Blue Shield Medicare Advantage lines and affiliated plan regions listed.

Policy Summary

PayerAnthem

PolicyMaximum Units Per Day reimbursement policy

Policy CodePolicy G-15003

Change TypeNo material change

Effective Date12/02/2025

Next Review Date

Key ActionWhen billing units that exceed the maximum allowed, provide documentation to support consideration of reimbursement and ensure services meet authorization and medical necessity requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12/02/2025Effective & last approval

G-15003Identifier

Multiple statesGeographic scope

UnaffectedNCCI interaction

Maximum Units Per Day Coverage Criteria

Maximum units per day coverage criteria

Reimbursement is allowed up to the plan's defined maximum units per day. Units exceeding that maximum are not eligible unless supported by documentation and meet authorization/medical necessity.

Allow reimbursement for a procedure or service billed for a single member on a single date of service by the same provider and/or provider group up to the maximum number of units allowed per day.

ALL of the following

Documentation and authorization: Provider must supply documentation supporting the medical necessity of units exceeding the maximum; services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.

Maximum units per day edits do not affect National Correct Coding Initiative (NCCI) edits; providers must also follow NCCI and standard correct coding and billing guidelines (CPT/HCPCS/revenue codes) and ensure services are supported in the medical record.

Policy Summary

PayerAnthem

PolicyMaximum Units Per Day reimbursement policy

Policy CodePolicy G-15003

Change TypeNo material change

Effective Date12/02/2025

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Billing Codes and Unit Standards

Billing codes and standardsmixed

CPT/HCPCS

Services should be billed with CPT, HCPCS, and/or revenue codes and be supported in the medical record.

inv-03: Maximum units per day

Billing allowanceProviders and provider groups may bill up to the plan's assigned maximum number of units per day for a procedure or service for a single member on a single date of service.

Excess units ineligibleUnits billed in excess of the maximum per day limit are not eligible for reimbursement unless documentation justifies consideration.

Documentation for excess unitsWhen a provider appropriately bills units that exceed the maximum allowed, documentation must be provided for consideration of reimbursement.

Interaction with NCCIMaximum units per day edits do not affect National Correct Coding Initiative (NCCI) edits; providers must also follow NCCI and standard correct coding.

Basis for maximumsMaximum units per day are determined based on claims data analysis.

Documentation and Authorization for Excess Units

Documentation Required

Documentation and Authorization for Excess Units

When a provider appropriately bills units that exceed the maximum units allowed, documentation must be provided for consideration of reimbursement. The documentation should clearly justify the medical necessity for the excess units and must be present in the medical record or office notes submitted with the claim. Maximum units per day edits do not affect National Correct Coding Initiative (NCCI) edits. The maximum units per day are based on claims data analysis. Review the Code and Clinical Editing Guidelines reimbursement policy for more information on NCCI edits.

Provide contemporaneous medical record or office notes that document the need for units billed in excess of the maximum.
Include clinical rationale tying excess units to the member’s condition, treatment response, or complication that necessitates additional units.
Attach any prior authorization or supporting authorization documentation if one was obtained for the excess units.
Ensure CPT/HCPCS/revenue codes and units billed are supported by the documentation to avoid denial or recovery.
Be aware that excess-unit documentation requests may result in claim review, adjustment, or recoupment if documentation is insufficient.

OpenPayer

Maximum Units Per Day reimbursement policy

Maximum Units Per Day Coverage Criteria

Billing Codes and Unit Standards

Documentation and Authorization for Excess Units

Definitions — Maximum Units