Maximum Units Per Day
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This reimbursement policy governs the maximum number of units per day that may be billed for a single member by the same provider or provider group for MMC, HARP, CHPlus, and Essential Plan members administered by Highmark BCBS WNY.
Note updated for clarity.
Maximum Units Per Day — Coverage Criteria
Maximum Units Per Day Coverage Criteria
Reimbursement criteria for billed units per day:
ALL of the following
- Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, and to the member's state of residence.
- Claims must use proper industry-standard CPT, HCPCS, and/or revenue codes and be fully supported in the medical record or office notes.
Coding and Unit Limits
| CPT/HCPCS/Revenue | Use standard CPT, HCPCS, and revenue codes; proper coding required on all claim submissions. |
Documentation and Authorization When Exceeding Daily Maximums
Provide documentation and meet authorization when billing over daily maximums
When billed units exceed the daily maximum, provide supporting documentation so excess units can be considered for reimbursement; services must also meet authorization and medical necessity guidelines. Ensure claims use proper CPT/HCPCS/revenue codes and that documentation fully supports billed services in the medical record or office notes.
- Submit medical record documentation that justifies units billed in excess of the assigned daily maximum for consideration of reimbursement.
- Confirm the service meets any applicable authorization and medical necessity requirements for the procedure, diagnosis, and member’s state of residence.
- Use industry-standard CPT, HCPCS, or revenue codes and ensure billed services are fully supported in the medical record or office notes.
Definitions — Maximum Units
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