CurrentBlue Cross Blue Shield - MainePolicy G-15003

Maximum Units Per Day

This reimbursement policy governs how many units of a procedure or service may be reimbursed per member, per date of service, by the same provider or provider group for AMH Health (Medicare Advantage). It affects providers submitting claims to AMH Health.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMaximum Units Per Day

Policy CodePolicy G-15003

Change TypeReview approved: no content changes

Effective Date06/16/2021

Next Review Date

Key ActionWhen units billed exceed the maximum per day, provide documentation for consideration of reimbursement and ensure services meet authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

Review approved: no changes on 12/19/2023 and 06/16/2021; initial approval and effective 01/01/2020.

G-15003policy identifier

3 review datespolicy history entries

maximum units per dayreimbursement concept

Coverage Criteria — Maximum Units Per Day

Maximum Units Per Day Criteria

Reimbursement stance regarding units billed per day:

AMH Health allows 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 unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

When the number of units assigned to a procedure or service exceeds the daily maximum allowed, the units billed in excess of the maximum per day limit will not be eligible for reimbursement.

When a provider appropriately bills units that exceed the maximum units allowed, documentation must be provided for consideration of reimbursement. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and member's state of residence.

Maximum Units Per Day edits do not affect National Correct Coding Initiative (NCCI) edits; see the Code and Clinical Editing Guidelines reimbursement policy for NCCI information.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyMaximum Units Per Day

Policy CodePolicy G-15003

Change TypeReview approved: no content changes

Effective Date06/16/2021

Next Review Date

Key ActionWhen units billed exceed the maximum per day, provide documentation for consideration of reimbursement and ensure services meet authorization and medical necessity guidelines.

SourceLink

On This Page

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Coding and Quantity Limits

Applicable Codingmixed

CPT	Use CPT codes to report professional procedures and services; codes must be supported in the medical record.
HCPCS	Use HCPCS codes where applicable; must be supported in the medical record.
Revenue	Use facility revenue codes where applicable on institutional claims.

Maximum units per day

Maximum units per dayAMH Health allows 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 unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Excess unitsWhen units billed exceed the daily maximum allowed, the units billed in excess will not be eligible for reimbursement. Documentation may be submitted for consideration when excess units are appropriately billed.

Relation to NCCIMaximum Units Per Day edits do not affect National Correct Coding Initiative (NCCI) edits. See Code and Clinical Editing Guidelines reimbursement policy for NCCI details.

Basis for limitsNote: The maximum units per day are based on claims data analysis.

Provider Actions — Documentation, Authorization, and Billing Compliance

Documentation Required

Documentation required when billed units exceed day limit

When billed units exceed the maximum allowed per day, providers must submit supporting documentation for consideration of reimbursement. AMH Health allows reimbursement for a procedure or service billed for a single member on a single date of service by the same provider/provider group up to the maximum units per day. Maximum Units Per Day edits do not affect NCCI edits. Note: Maximum units per day are based on claims data analysis.

Maximum units per day are based on claims data analysis.
Maximum Units Per Day edits do not affect NCCI edits.

Denial Risk

Billing compliance consequences

Failure to follow coding, billing, or submission guidelines may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement to reflect the appropriate services performed. These policies do not replace provider, state, federal, or CMS contract requirements; where mandates differ, those requirements apply. Providers are required to use industry-standard CPT, HCPCS, and/or revenue codes and fully support billed services in the medical record.

If appropriate coding/billing guidelines or current reimbursement policies are not followed, AMH Health may: Reject or deny the claim; Recover and/or recoup claim payment; Adjust the reimbursement to reflect the appropriate services and/or procedures performed.
Services must be billed with CPT, HCPCS, and/or revenue codes and supported in the medical record.

OpenPayer

Maximum Units Per Day

Coverage Criteria — Maximum Units Per Day

Coding and Quantity Limits

Provider Actions — Documentation, Authorization, and Billing Compliance

Definitions — Maximum Units