CurrentUnitedHealthcarePolicy 2026R0060C

Maximum Frequency Per Day (MFD) reimbursement policy for CMS-1500 billed services

Governs UnitedHealthcare reimbursement limits (MFD values) for units billed on CMS-1500 (and electronic equivalent) for UnitedHealthcare Commercial and Individual Exchange benefit plans; affects network and non-network physicians and other qualified health care professionals (excludes certain provider types listed).

Policy Summary

PayerUnitedHealthcare

PolicyMaximum Frequency Per Day (MFD) reimbursement policy for CMS-1500 billed services

Policy CodePolicy 2026R0060C

Change TypeClarification and updates (Q&A added; attachments updated)

Effective Date

Next Review Date

Key ActionWhen units exceed MFD (except for MAI2 codes), submit the appropriate modifier (59, 76, 91, XE, XS, XU) to allow additional reimbursement and retain documentation supporting the units.

SourceLink

POLICY UPDATE CHANGES

Added Q&A clarifying CPT 95165 dose definition and CMS MFD/MUE reimbursement limits per vial.

Policy lists for MFD CPT, MFD HCPCS, Codes Restricting Modifiers LT and RT, and MAI2 Indicator Codes were updated multiple times (entries through 4/26/2026 shown).

999default MFD for drug HCPCS codes when no other value established

100default MFD for new CPT/HCPCS codes when no other value established

50+threshold for statistical MFD

MAI2 codes (no override allowed)

multiplepolicy history entries

MFD Determination and Application

MFD determination and reimbursement criteria

Rules to determine MFD values and reimbursement treatment when billed units exceed the MFD.

ALL of the following

Use CMS MUE value where available to establish MFD (including unlisted codes).
If service is classified as bilateral (NPFS indicator 1 or 3) or descriptor includes 'bilateral' and no MUE exists, set MFD = 1 (exceptions where descriptor treats multiple anatomical sites may have MFD > 1).
If CPT/HCPCS descriptor explicitly indicates the number of times the service may be performed, set MFD to that value.
If the service is anatomically or clinically limited (e.g., anatomical site, vertebral level, dosage, units of measure, coding guidelines), set MFD to that clinically or anatomically limited value (example: appendectomy MFD = 1).
If a DME MAC LCD assigns an MFD value, adopt that LCD MFD value.
If no definitive value and code is a drug HCPCS, set MFD = 999 (this bypasses the MFD policy for drug HCPCS codes).

ALL of the following

If code has >= 50 claim occurrences (excluding HCPCS drug codes), set MFD at the 100th percentile (highest units billed in data set). If the 100th percentile exceeds the 98th percentile by a factor greater than 4, set MFD at the 98th percentile instead.
If code has < 50 claim occurrences (excluding HCPCS drug codes), set MFD default = 100 until next annual analysis.
UnitedHealthcare may, in its judgment, increase an MFD where the 98th percentile does not account for clinical circumstances so as to capture only obvious billing or data entry errors.

ALL of the following

For codes not assigned MAI indicator = 2, UnitedHealthcare may consider additional reimbursement for units exceeding MFD when reported with an appropriate modifier (examples: 59, 76, 91, XE, XS, XU). Medical records are not required to be submitted with the claim when such modifiers are appropriately reported, but documentation should support the units and modifier use.
For CPT/HCPCS codes assigned MAI indicator = 2, units in excess of the MFD will not be reimbursed and no modifier override is allowed; anatomic modifiers may be considered when appropriate.
LT/RT modifiers on codes where laterality does not apply are informational only; UnitedHealthcare will pay up to the MFD for the same provider on the same date of service whether or not LT/RT is submitted.

ALL of the following

Most current MFD values, MFD CPT/HCPCS Code Values lists, and MFD MAI2 Indicator Codes are provided in attachments to the policy.
Policy applies to services billed on CMS-1500 (or electronic equivalent) and may apply to UB-04 when specified; excludes certain provider types as described in the policy.

Top-level application note: When none of the Part I criteria apply, proceed to Part II statistical rules to set MFD as described above.

MFD and units reporting criteria

Guidance for reporting units and limits per date of service:

ALL of the following

Each vaccine component administration may be reported on separate lines (e.g., multiple lines for 90460 and 90461 with 1 unit each).
When reporting the same CPT/HCPCS code on multiple lines and/or separate claims, additional claim lines with the same procedure code may be denied as duplicate service.
UnitedHealthcare follows CDC ACIP recommendations to set MFD for immunization administration codes (example: determination for 90472 and 90474 follows ACIP).

ALL of the following

Services with descriptors containing 'single lesion', 'XX or more lesions', or 'per date of service' should be reported with 1 unit of service.

Codes, Thresholds, and Coding Rules

MAI2 codesmixedNot Covered

MAI2 Indicator Codes (attachment list)

Codes assigned MAI indicator '2' where units above MFD are impossible per CMS and no modifier override allowed

Immunization administration examplesCPT

90460, 90461

Immunization administration codes — multiple components may be reported as multiple units or separate lines; MFD determination follows ACIP guidance

Immunization and related administration codesCPTCovered

90460	Immunization administration (intramuscular/oral) - used for various vaccines per guidance
90461	Immunization administration, additional vaccine component
95165	Allergen extract dose — defined as one 1 cc aliquot from a multidose vial (CMS defines max 10 doses per vial)

inv-06: claim occurrence threshold for data analysis

Claim occurrence threshold for data analysis50 claim occurrences in a data set (excluding HCPCS drug codes) — codes with >=50 occurrences are analyzed and MFD set by claim data (100th percentile, with 98th-percentile adjustment).

Below-threshold defaultIf a code (excluding HCPCS drug codes) has <50 claim occurrences, MFD is set to a default of 100 until the next annual analysis.

Drug code exclusionHCPCS drug codes are excluded from the 50-claim data-analysis threshold rule; separate handling applies for drug HCPCS (see drug default rules).

inv-07: Default MFD for new codes

Default MFD for new CPT/HCPCS codesWhen no CMS MUE value or claims history exists, new CPT/HCPCS codes are assigned a default MFD value of 100 to allow processing and reduce overpayments.

Billing, Modifiers, and Documentation Guidance

Billing Rule

Modifier override process for exceeding MFD (except MAI2)

There may be situations where a physician or other qualified health care professional reports units accurately and those units exceed the established maximum frequency per day (MFD) value. In such cases, UnitedHealthcare will consider additional reimbursement if the claim is reported with an appropriate modifier to explain the separate and distinct service. Applicable modifiers include: 59, 76, 91, XE, XS, and XU. Medical records are not required to be submitted with the claim when one of these modifiers is appropriately reported. However, documentation within the medical record should reflect the number of units being reported and should support the use of the modifier.

Applicable modifiers for modifier override process: 59, 76, 91, XE, XS, XU
Modifiers LT/RT: Bilateral payment via LT/RT is inappropriate where laterality does not apply; LT/RT on restricted codes is informational only
When modifiers 59/76/91/XE/XS/XU are used appropriately, medical records are not required to be submitted with the claim but documentation should support the units billed

Key Terms and Indicators

inv-11: The number of times services with the same CPT or HCPCS code are provided per day by the same individual provider.

Definition: Units (per-provider per-day)The number of times services with the same CPT or HCPCS code are provided per day by the same individual provider.

Applies to claim line formatsIncludes submission of one CPT/HCPCS code with multiple units on a single claim line or multiple claim lines with units.

PurposeUsed to establish MFD values that limit reimbursement to the highest eligible number of units on a single date of service and to prevent obvious billing/data entry errors.

inv-12: The same individual rendering services reporting the same Federal Tax Identification number.

Definition: Same individual providerThe same individual rendering services reporting the same Federal Tax Identification number.

Policy Summary

PayerUnitedHealthcare

PolicyMaximum Frequency Per Day (MFD) reimbursement policy for CMS-1500 billed services

Policy CodePolicy 2026R0060C

Change TypeClarification and updates (Q&A added; attachments updated)

Effective Date

Next Review Date

Key ActionWhen units exceed MFD (except for MAI2 codes), submit the appropriate modifier (59, 76, 91, XE, XS, XU) to allow additional reimbursement and retain documentation supporting the units.

SourceLink

On This Page

ALL of the following

New CPT/HCPCS codes without a CMS MUE or claim history are assigned a default MFD = 100 to allow processing and to reduce overpayments from billing/data entry errors until CMS MUE or claims data are available.
MFD is set at the 100th percentile unless the 100th percentile exceeds the 98th percentile by a factor greater than 4; if so, set MFD at the 98th percentile. Examples in the policy illustrate the calculation and final assignment (e.g., CPT 86902 set MFD = 27; E0676 set MFD = 2).

CMS MUE adherence note: Providers will not be reimbursed for more than the CMS MFD/MUE value per day (example: CPT 95165 defined as one 1 cc aliquot from a multidose vial; CMS allows max 10 doses per vial).

Transition to established MFDOnce CMS MUE or claims data are available, MFD will be established according to the policy hierarchy (CMS MUE, descriptor limits, data analysis).

RationaleDefault of 100 prevents claim denials and reduces overpayments from billing or data entry errors until analysis can be completed.

inv-08: MFD determination rule (98th vs 100th percentile with factor of 4)

Primary rule (100th percentile)When data analysis applies (>=50 claim occurrences), set MFD at the 100th percentile (highest units billed) unless adjusted per the factor rule.

98th-percentile adjustment (factor of 4)If the 100th percentile exceeds the 98th percentile by a factor greater than 4 (i.e., 98th × 4 < 100th), set MFD at the 98th percentile instead of the 100th.

Judgment exceptionUnitedHealthcare may increase MFD where the 98th percentile does not account for clinical circumstances, to capture only obvious billing or data-entry errors.

Billing Rule

Vaccine administration billing guidance

Report vaccine administration codes to reflect each component administered. It is appropriate to report administration of each vaccine component on separate lines (for example, multiple lines of 90460 and 90461 with 1 unit each), but when reporting the same CPT or HCPCS code on multiple lines and/or on separate claims the additional line(s) may be denied as duplicate services. UnitedHealthcare follows CDC/ACIP recommendations to set MFD values for immunization administration CPT codes (for example 90472 and 90474). Ensure claims reflect the correct CPT/HCPCS administration codes and units for each vaccine component and be aware of duplicate claim denials when identical codes are reported multiple times.

Report each vaccine component administration on separate lines when appropriate (e.g., multiple 90460 and 90461 lines with 1 unit each)
Identical CPT/HCPCS lines reported multiple times may be denied as duplicate services
MFD values for codes such as 90472 and 90474 follow CDC/ACIP recommendations

Definition applies for counting units and applying MFD per date of service under this policy.

Implication for claimsMFD evaluation compares units billed by the same individual (same TIN) on the same date to determine eligibility for reimbursement up to the MFD.

inv-13: MFD

TermMFD (Maximum Frequency per Day) — the highest number of units eligible for reimbursement of services on a single date of service.

How MFD is establishedMFD values are set using CMS MUE when available, CPT/HCPCS descriptors, anatomical/clinical limits, DME LCDs, or claim data analysis per policy hierarchy.

Evaluation cadenceMFD values are evaluated and/or updated quarterly to reflect new, changed, and deleted codes; attachments list current MFD CPT/HCPCS values.

inv-14: MAI2 Indicator Codes

MAI2 meaningMAI2 Indicator Codes are codes CMS identified where Units of Service on the same date in excess of the MUE value would be considered impossible.

Modifier overrides not allowedFor codes with MAI indicator 2, units in excess of MFD will not be reimbursed and no modifier override is allowed; anatomic modifiers may be considered where appropriate.

AvailabilityMAI2 Indicator Codes are provided in the policy attachments (MAI2 Indicator Codes list) for reference.