CurrentColorado Rocky Mountain Health PlansPolicy N/A

Maximum Frequency per Day (MFD) reimbursement policy

Defines limits and reimbursement rules for the number of units (MFD values) payable per date of service for CPT and HCPCS codes for UnitedHealthcare Community Plan Medicaid products and providers submitting CMS-1500/UB04 claims.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMaximum Frequency per Day (MFD) reimbursement policy

Policy CodePolicy N/A

Change TypeNo material change / informational

Effective DateN/A

Next Review DateN/A

Key ActionWhen billed units exceed the MFD, report appropriate modifiers (59, 76, 91, XE, XS, XU) to support reimbursement; documentation is not required with the claim unless appealed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MUE > MFDpolicy precedence

999default exempt MFD

100default for new codes

≥50 claimsdata analysis rule

59,76,91,XE,XS,XUmodifier exceptions

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Maximum Frequency per Day (MFD) — Coverage Rules

inv-01: MFD determination and reimbursement criteria

Rules to establish MFD values and reimbursement treatment:

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ALL of the following

If the code has >= 50 claim occurrences in the data set, set MFD to the 100th percentile (the highest number of units billed for that code in the data set).
100th percentile rule for >=50 occurrences.
If the 100th percentile exceeds the 98th percentile by a factor of four, set MFD = 98th percentile instead of the 100th.
Cap extreme outliers: 98th percentile adjustment when 100th > 98th x4.
If the code has < 50 claim occurrences, set MFD = 100 until the next annual analysis.
Default for low-occurrence codes.
UnitedHealthcare Community Plan may increase an MFD above the statistical percentile when the 98th percentile does not account for legitimate clinical circumstances; MFD lists in attachments contain the most current values.
Judgment-based increases and attachments.

ALL of the following

Services are reimbursable up to and including the MFD value for an individual CPT/HCPCS code whether units are on a single claim line or multiple lines; reporting the same code on multiple/separate claim lines may be classified as duplicate service.
Single-line vs multiple-line reporting and duplicate risk.
When units billed exceed the established MFD and are accurate, UnitedHealthcare Community Plan will consider additional reimbursement if reported with an appropriate modifier (examples: 59, 76, 91, XE, XS, XU). Medical records are not required to be submitted with the claim solely because of these modifiers, but documentation should support modifier use and must be available if the claim is appealed.
Modifier-based reimbursement consideration.
Use of laterality modifiers LT/RT on codes where laterality does not apply is informational only; payment up to the MFD will be made whether submitted with or without LT/RT by the same individual on the same date of service.
LT/RT informational only for non-laterality codes.

ALL of the following

MFD values are reviewed and may be updated quarterly to reflect code changes and claim data analysis.
Quarterly review frequency.
Policy applies to services billed on CMS-1500 (and UB04 when specified) for UnitedHealthcare Community Plan Medicaid products and to network and non-network providers as described.
Scope of application.

inv-02: Coverage criteria for MFD

Stance on unit limits and exceptions; describes when more than MFD may be allowed and how units should be billed.

General rule: Providers must bill units up to the assigned MFD for a code unless a state exception or appropriate modifier justifies additional units.

State-specific exceptions (examples)

Examples include: VA exemptions (e.g., S0109 exempt; various behavioral health and H‑series codes with specified unit allowances), Washington exceptions (codes with 2–5 units or no daily limits), and Wisconsin exceptions (examples: T1019 allowed 96 units/day; vaccine administration reporting guidance).
See state lists in attachments for complete details.

ALL of the following

When billed units exceed MFD and those units are accurate, use an appropriate modifier (e.g., 59, 76, 91, XE, XS, XU) to support additional reimbursement. Medical records are not required with the claim solely for this policy when modifiers are properly reported, though documentation should support modifier use and must be provided if appealing a claim decision.

Coding Rules, Defaults and State Exceptions

Default exemptions and new codesmixed

drug HCPCS / unlisted codes	Default MFD = 999 (exempt from MFD policy)
new CPT/HCPCS codes since last update	Default MFD = 100 (until claims data available)

Selected state exception codesmixed

G2211	Excluded as non-covered per state guidance
S0109	VA exempt from MFD limits
T1019	Allowed 96 units per day in Wisconsin

inv-05: Claim occurrence threshold for data-driven MFD

Claim occurrence thresholdWhen a code has 50 or more claim occurrences, MFD is determined from claim data and set at the 100th percentile; if the 100th percentile exceeds the 98th percentile by a factor of four, set MFD at the 98th percentile.

Less than 50 occurrencesIf a code has fewer than 50 claim occurrences, default MFD is set to 100 until the next annual analysis.

Purpose of thresholdThreshold triggers data-driven analysis to reflect common billing patterns when Part I criteria do not apply.

inv-06: Default MFD for new CPT/HCPCS

Default MFD for new CPT/HCPCSNew CPT and HCPCS codes released since the last MFD update default to an MFD value of 100 until claims data are available.

Billing, Modifiers, and Documentation Guidance

Prior Authorization

Report appropriate modifiers (59, 76, 91, XE, XS, XU) when units exceed MFD

Providers may report modifiers 59, 76, 91, XE, XS, or XU when billed units exceed the established MFD to indicate distinct services or separate encounters; when these modifiers are appropriately reported, medical records do not need to be submitted with the claim. Documentation in the medical record should reflect the number of units reported and support the use of the modifier.

Modifiers listed: 59, 76, 91, XE, XS, XU
Medical records not required with claim when such modifiers are appropriately reported
Medical record documentation should support modifier use and number of units billed

Documentation Required

Use specified modifiers and retain documentation for appeals; beware duplicate-line denials

When billed units exceed the MFD and are accurate, report an appropriate modifier (59, 76, 91, XE, XS, XU); medical records are not required solely for this policy unless the claim is appealed. Note that duplicate claim lines for the same code may be classified as duplicate services and subject to denial under other reimbursement policies.

Key Terms and Policy Definitions

inv-10: Definition

Units (definition)The number of times services with the same CPT or HCPCS code are provided per day by the same individual physician or other qualified health care professional.

Application to claimsApplies whether services are billed as multiple units on one line or on multiple claim lines.

PurposeUsed to establish Maximum Frequency per Day (MFD) values to limit reimbursement for obvious billing errors or incorrect coding.

inv-11: Definition

Same individual (definition)The same individual rendering health care services who reports the same Federal Tax Identification Number.

RelevanceDetermines how 'units' are attributed for MFD calculations (per individual provider per date of service).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyMaximum Frequency per Day (MFD) reimbursement policy

Policy CodePolicy N/A

Change TypeNo material change / informational

Effective DateN/A

Next Review DateN/A

Key ActionWhen billed units exceed the MFD, report appropriate modifiers (59, 76, 91, XE, XS, XU) to support reimbursement; documentation is not required with the claim unless appealed.

SourceLink

On This Page

Modifier and documentation guidance.

Bilateral and per-day billing rules

Bilateral procedures: preferred billing is a single line with modifier 50 or two lines with RT/LT; MFD for most bilateral-eligible procedures is set to 1. If performed multiple times on the same date, other modifiers may apply.
Bilateral billing guidance.
Per‑day codes and codes described as 'per diem' or 'per day' are limited to 1 unit; modifiers cannot be used to override MFD for these codes.
Per-day code limitation.

ALL of the following

New CPT/HCPCS codes default to an MFD of 100 until claims data permit setting a specific MFD via the statistical method.
New code default MFD.
Reporting the same code on multiple claim lines may be denied as duplicate service even if each line has 1 unit; providers should follow guidance on single-line vs. multiple-line reporting to avoid denials.
Duplicate line risk.

Reason for defaultSetting new codes to 100 allows claims processing and helps prevent overpayments due to billing or data entry errors when no prior data exist.

Update timingOnce sufficient claims data are available, the code’s MFD will be established through data analysis and quarterly review.

inv-07: Default MFD for new codes

Statistical rule for setting MFDWhen data are available, set MFD at the 100th percentile; if the 100th percentile exceeds the 98th percentile by a factor of four, set MFD at the 98th percentile.

Temporary MFD until data availableSet new codes at an MFD of 100 until claim data permit statistical determination.

Example calculationStatistical calculation: (98th percentile) x 4 = threshold; if 100th percentile is greater than that threshold, use 98th percentile; otherwise use 100th percentile.

If claim is appealed, medical records must be submitted to support billed units and modifier use
Multiple claim lines with the same code may be treated as duplicate services

ScopeApplies to physicians and other qualified health care professionals covered by the policy.

inv-12: Definition

Policy precedenceCMS Medically Unlikely Edits (MUE) values always supersede MFD values listed in this policy, except in Arizona.

Order of applicationIf a CMS MUE exists, UnitedHealthcare Community Plan follows the CMS MUE before applying other MFD criteria.

ReferenceSee UnitedHealthcare Community Plan’s Medically Unlikely Edits Policy for details.

inv-13: Definition

MFD as reimbursement thresholdMFD is a threshold established to prevent overpayment due to billing submission and data entry errors and represents the maximum units allowable per date of service for a given code.

Reimbursement intentUnitedHealthcare Community Plan intends to reimburse services accurately reported with proper coding even if units exceed MFD when appropriate modifiers are used.

Review cadenceMFD values are evaluated and updated quarterly to reflect new, changed, and deleted codes.