CurrentHighmark Blue Cross Blue Shield WnyPolicy G-15003

Maximum Units Per Day

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.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyMaximum Units Per Day

Policy CodePolicy G-15003

Change TypeClarification

Effective Date12/02/2025

Next Review Date

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

SourceLink

POLICY UPDATE CHANGES

Note updated for clarity.

G-15003Policy identifier

12/02/2025Effective / Last approval date

MMC, HARP, CHPlus, EPPrograms covered

Claims analysisBasis for maximum units per day

Maximum Units Per Day — Coverage Criteria

Maximum Units Per Day Coverage Criteria

Reimbursement criteria for billed units per day:

Allow reimbursement up to the assigned maximum number of units per day for a procedure/service billed for a single member by the same provider or provider group, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Units billed in excess of the assigned daily maximum are not eligible for reimbursement.

When billed units exceed the daily maximum, documentation must be provided for consideration of reimbursement.

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.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyMaximum Units Per Day

Policy CodePolicy G-15003

Change TypeClarification

Effective Date12/02/2025

Next Review Date

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

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Unit Limits

Required coding systemsmixed

CPT/HCPCS/Revenue

Use standard CPT, HCPCS, and revenue codes; proper coding required on all claim submissions.

Maximum units per day — policy summary

Policy on billing above daily maximumUnits billed above the assigned maximum number of units per day are not eligible for reimbursement unless appropriate documentation is provided for consideration.

ApplicabilityApplies to procedures/services billed for a single member on a single date of service by the same provider and/or provider group, unless provider, state, federal, or CMS requirements indicate otherwise.

Documentation requirementWhen a provider appropriately bills units that exceed the maximum, documentation must be submitted for reimbursement consideration; services must still meet authorization and medical necessity guidelines.

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

Basis for maximumsMaximum units per day are established based on claims data analysis.

Documentation and Authorization When Exceeding Daily Maximums

Documentation Required

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.

OpenPayer

Maximum Units Per Day

Maximum Units Per Day — Coverage Criteria

Coding and Unit Limits

Documentation and Authorization When Exceeding Daily Maximums

Definitions — Maximum Units