CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Maximum Units (unit of service claim edits)

This payment policy governs maximum unit values (service quantity edits) applied to professional and outpatient facility claims coded with CPT or HCPCS codes for Blue Cross & Blue Shield of Rhode Island members, affecting providers submitting claims for Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMaximum Units (unit of service claim edits)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2023

Next Review DateN/A

Key ActionPrior authorization is not applicable; apply maximum unit edits to professional and outpatient facility claims per CMS MUEs or BCBSRI limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT/HCPCScode scope

professional & outpatientclaim types affected

includes MUEsCMS MUE reference

Jul 2023publication

Maximum Units Coverage Rules

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Maximum Units Coverage Rules

Covered when the following application rules are met:

Applies to all professional and outpatient facility claims coded with a CPT or HCPCS code that has a maximum unit value/edit.

Maximum unit value applies regardless of whether the code is reported on one line, multiple lines, or multiple claims for the same provider and member.

ALL of the following

ONE OR MORE OF
- CMS Medically Unlikely Edits (MUEs); not all CPT/HCPCS codes have an MUE assigned by CMS.
- CMS MPFS bilateral indicators (Indicator 1 or 3) or the term 'bilateral' included in the code descriptor.
- Service is anatomically or clinically limited with regard to the number of times it may be reported.
- CPT or HCPCS code description specifies the number of times it can be reported during a specific time period.
- Quantity submitted exceeds historic standard practice and is unlikely based upon analysis of claims data.
- Limits determined by Blue Cross & Blue Shield of Rhode Island related to reasonable usage/provision of service.

Other limits to the frequency of services may apply based on factors outside this policy (for example, member benefit limits or medical necessity frequency as defined in a medical policy).

POTENTIAL EXCEPTIONS: Some procedure codes may be non-covered, investigational, have a medical policy limit, or require medical review.

Maximum Unit Values and Determination

Maximum unit valuesmixed

No codes listed

inv-03: Maximum units per code 6 determinants

Primary determinantsCMS Medically Unlikely Edits (MUEs); note not all CPT/HCPCS codes have an MUE assigned by CMS.

Bilateral indicatorsCMS MPFS bilateral classification (Indicator 1 or 3) or 'bilateral' included in the code descriptor can set maximum units.

Code descriptors and clinical/anatomic limitsCodes with descriptors that specify frequency or services that are anatomically/clinically limited determine maximum units.

Historical usage analysisQuantities that exceed historic standard practice based on claims data analysis may be limited.

BCBSRI determinationsLimits may be established by Blue Cross & Blue Shield of Rhode Island for reasonable usage/provision of service (BCBSRI-specific maximum units).

Key Terms

inv-05: unit of service claim edits 6 definition of Maximum unit values

DefinitionMaximum unit values are unit-of-service claim edits applied to a claim(s) against a specific CPT and/or HCPCS procedure code for services rendered to a member over a period of time.

Scope of applicationApplies to professional and outpatient facility claims coded with a CPT or HCPCS code that has a maximum unit value/edit; applies regardless of whether the code is reported on one line, multiple lines, or multiple claims.

Timeframe behaviorValues may limit units for the same provider and member on the same calendar date of service, over a specified period, or over a member's lifetime.

Relation to CMS MUEsMaximum unit values include but are not limited to CMS Medically Unlikely Edits (MUEs); not all codes have an MUE.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMaximum Units (unit of service claim edits)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2023

Next Review DateN/A

Key ActionPrior authorization is not applicable; apply maximum unit edits to professional and outpatient facility claims per CMS MUEs or BCBSRI limits.

SourceLink

On This Page

OpenPayer

Maximum Units (unit of service claim edits)

Maximum Units Coverage Rules

Maximum Unit Values and Determination

Prior Authorization and Provider Requirements

Key Terms