CurrentMolina HealthcarePolicy N/A

Medically Unlikely Edits (MUE) / NCCI reimbursement policy

Defines Molina Healthcare's application of CMS National Correct Coding Initiative (NCCI) edits and Medically Unlikely Edits (MUEs) for claim adjudication and provider reimbursement across Medicare, Medicaid, and Marketplace lines; includes update cadence and state exceptions.

Policy Summary

PayerMolina Healthcare

PolicyMedically Unlikely Edits (MUE) / NCCI reimbursement policy

Policy CodePolicy N/A

Change TypeTemplate and supplemental updates (non-material)

Effective DateN/A

Next Review DateN/A

Key ActionProviders must follow industry standard coding practices; improper billing/coding may lead Molina to reject/deny claims and recover payments.

SourceLink

POLICY UPDATE CHANGES

Updated Supplemental Information and State Exceptions.

Updated Template.

Verified Links updated Template.

QuarterlyNCCI edit update frequency

By 15th next monthImplementation timeframe

ThreeMUE file types

1/dayExample MUE (A4253)

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NCCI / MUE coverage and adjudication rules

Application of NCCI and MUEs to claim processing and denial behavior.

Molina applies CMS Medicare NCCI edits to Medicare and Marketplace claims and CMS Medicaid NCCI edits to Medicaid claims.

MUEs specify maximum units of service for HCPCS/CPT codes per beneficiary per single date of service; if billed units exceed the MUE value the entire claim line will be denied.

MUEs are daily limits and apply even when separate benefit limits exist (for example, coverage limited to 3 boxes/month but MUE of 1 per day enforces daily supply).

There are three MUE file types: Practitioners; ASCs and outpatient hospitals; and DME providers.

Provider billing format affects line-item reporting: providers billing on a UB04 must bill each date as a separate line item; providers billing on a 1500 can generally bill date spans.

Not all HCPCS/CPT codes have an MUE.

Code Examples and Unit Limits

Example code with MUEHCPCSCovered

A4253

Box of 50 glucose test strips (example MUE of 1 per day)

MUE unit limit

DefinitionMaximum units per code per beneficiary per single date of service as specified in CMS MUE files.

Claim behavior when exceededIf more units are reported on a claim line than the MUE value for the code, the entire claim line will be denied.

ScopeNot all HCPCS/CPT codes have an MUE; three MUE file types exist (Practitioners; ASCs and outpatient hospitals; DME providers).

Daily limit natureMUEs are daily limits and apply even when a separate benefit limit exists (e.g., monthly limits).

Billing noteProviders billing on a UB04 must bill each date as a separate line item; providers billing on a 1500 can generally bill date spans.

Billing, Documentation, and Provider Responsibilities

Billing Rule

Provider billing and documentation responsibility

Providers must follow industry standard coding practices; improper billing/coding may lead Molina to reject/deny claims and recover payments.

Follow nationally accepted industry standards and coding principles when preparing claims.
Improper billing or coding may result in claim rejection or denial and Molina recovering payments.

Key Terms

CMS

Agency nameThe Centers for Medicare & Medicaid Services (CMS).

RoleFederal agency that administers the Medicare program and works with state governments to administer Medicaid and the Children's Health Insurance Program (CHIP).

ContextCMS issues National Correct Coding Initiative (NCCI) edits and Medically Unlikely Edits (MUEs) used in claims adjudication.

MUE

DefinitionMedically Unlikely Edits (MUE): edits that define the maximum units of service that would be unlikely if the claim is reported correctly.

PurposeUtilized by Medicare Administrative Contractors to reduce improper payments by limiting maximum units reported per code per beneficiary per date of service.

File typesThere are three MUE files: Practitioners; ASCs and outpatient hospitals; DME providers.

Adjudication impactIf reported units exceed the MUE value the entire claim line will be denied.