CurrentEmpire BluecrossPolicy G-15003

Maximum Units Per Day (Reimbursement)

This policy governs Anthem/Empire Medicare Advantage reimbursement limits for the maximum number of units of a procedure or service that may be billed for a single member on a single date of service by the same provider or provider group. It affects providers submitting claims to Empire/Anthem Medicare Advantage in the listed states.

Policy Summary

PayerEmpire Bluecross

PolicyMaximum Units Per Day (Reimbursement)

Policy CodePolicy G-15003

Change TypeNo material changes

Effective DateJun 16, 2021

Next Review Date

Key ActionProvide documentation when billing units that exceed the daily maximum to be considered for reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

maximum units enforcedpolicy enforces a daily maximum units limit for billed procedures/services

single member/date/providerscope of the unit limit

documentation requiredproviders may submit documentation when billing units in excess of the maximum

12/19/2023policy last reviewed/approved

Reimbursement Criteria

Maximum units per day reimbursement criteria

Reimbursement rules for units billed per date of service:

Provider may bill up to the maximum number of units allowed per day for a procedure or service for a single member on a single date of service by the same provider or provider group.

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.

Provider should submit supporting medical record documentation to justify units in excess of the daily maximum.

Maximum units per day edits do not affect National Correct Coding Initiative (NCCI) edits; NCCI rules remain applicable.

Policy Summary

PayerEmpire Bluecross

PolicyMaximum Units Per Day (Reimbursement)

Policy CodePolicy G-15003

Change TypeNo material changes

Effective DateJun 16, 2021

Next Review Date

Key ActionProvide documentation when billing units that exceed the daily maximum to be considered for reimbursement.

SourceLink

On This Page

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Coding and Unit Limits

Billing code requirementsmixed

No codes listed

Maximum units per day — reimbursement rules

Daily billing limitProvider may bill up to the assigned maximum number of units per day for a procedure or service for a single member on a single date of service by the same provider or provider group.

Excess units ineligibleUnits billed in excess of the daily maximum will not be eligible for reimbursement unless the provider submits documentation for consideration.

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

Relationship to NCCI editsMaximum units per day edits do not affect National Correct Coding Initiative (NCCI) edits; NCCI rules remain applicable.

Required Provider Documentation and Actions

Documentation Required

Excess units documentation

When billed units for a procedure or service exceed the maximum allowed per member per day, units billed in excess will not be eligible for reimbursement unless supporting documentation is provided. If a provider appropriately bills units that exceed the maximum units allowed, submit documentation that justifies medical necessity for the additional units so the claim can be considered for reimbursement. Note that maximum units-per-day edits do not affect National Correct Coding Initiative (NCCI) edits.

Applies when a procedure/service is billed for a single member on a single date of service by the same provider or provider group and the billed units exceed the daily maximum.
Documentation must substantiate why units beyond the maximum were necessary (medical record notes, treatment rationale, time logs, etc.).
Maximum units per day are determined based on claims data analysis and payer edits.
NCCI edits remain independent — units-per-day limits do not override NCCI edits.

OpenPayer

Maximum Units Per Day (Reimbursement)

Reimbursement Criteria

Coding and Unit Limits

Required Provider Documentation and Actions

Definitions