CurrentUnitedHealthcarePolicy 2025R7117I

Reimbursement Policy CMS 1500 and UB04

Defines UnitedHealthcare Community Plan's reimbursement approach for services billed on CMS-1500 and UB04 forms, including application of CMS Medically Unlikely Edits (MUEs), state exceptions, and provider responsibilities; affects providers billing UnitedHealthcare Community Plan Medicaid products.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy CMS 1500 and UB04

Policy CodePolicy 2025R7117I

Change TypeState exceptions updatedIdaho addedQ&A added

Effective Date

Next Review Date

Key ActionEnsure claims are submitted with accurate coding and documentation to support units of service; appeals are permitted when MUEs are based on Medicare/Medicaid data.

SourceLink

POLICY UPDATE CHANGES

State Exceptions: North Carolina updated

Idaho added to State Exceptions

Questions and Answers Section: Added #2

All units deniedconsequence when units exceed MUE

Community Plan Medicaidapplies to

Multiple listedstate exceptions

Follow CMS firstMUE priority

Coverage Criteria & Application

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy CMS 1500 and UB04

Policy CodePolicy 2025R7117I

Change TypeState exceptions updatedIdaho addedQ&A added

Effective Date

Next Review Date

Key ActionEnsure claims are submitted with accurate coding and documentation to support units of service; appeals are permitted when MUEs are based on Medicare/Medicaid data.

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.

MUE / MFD Coverage Criteria

MUE/MFD coverage criteria — Application of CMS MUEs, order of operations, documentation and appeal guidance

ALL of the following

UnitedHealthcare Community Plan follows CMS MUE values before applying any other Maximum Frequency Per Day (MFD) criteria.
If a CMS MUE value does not exist for a HCPCS/CPT code, or the reported units do not exceed the CMS MUE value, the UnitedHealthcare Community Plan Maximum Frequency Per Day Policy will be applied.
Medically Unlikely Edits (MUEs) define the maximum allowable units of service by the same provider, for the same beneficiary, on the same date of service, on the same claim line. Units reported greater than the established MUE will be denied for Professional and Facility claims; all units on that claim line will be denied if the reported units exceed the MUE value.
For the purposes of this policy, the same individual physician or qualified health care professional is defined as the same individual rendering services who reports the same Federal Tax Identification Number.
Documentation requirements: Medical record documentation must support that: (1) the correct HCPCS/CPT code is reported; (2) the correct units of service (UOS) are reported; (3) the number of reported UOS were actually performed; and (4) all reported UOS were medically reasonable and necessary.
Provide clear date/time, procedure details, and linkage to medical necessity to support units > MUE.
Appeals: If a denial is received for a code where the MUE was established using Medicare/Medicaid data (MUE Rationale includes 'Medicaid Data' or Medicare policy/data), the denial may be appealed. Include supporting medical record documentation per the documentation requirements above.
Regulatory context: Section 6507 of the Affordable Care Act requires State Medicaid programs to implement NCCI-compatible methodologies, which include NCCI Procedure-to-Procedure (PTP) edits and MUEs; states incorporated these methodologies for Medicaid claims filed on or after October 1, 2010.

Coding Rules, State Exceptions, and Priority

Covered HCPCSHCPCSCovered

A4253	Wheelchair accessory/part, specific - exempt from MUE per North Carolina state regulations
A4287	Power wheelchair component - exempt from MUE per North Carolina state regulations
A4238	Manual wheelchair component - exempt from MUE per North Carolina state regulations
A4271	Wheelchair other part - exempt from MUE per North Carolina state regulations
A4332	Wheelchair seating/positioning component - exempt from MUE per North Carolina state regulations

Covered HCPCS (daily/quantity-limited)HCPCSCovered

G0155	Services of physical therapist in the home health or hospice setting - 16 units per day allowed per North Carolina state regulations
S9442	Patient education/ training for a specific condition - 4 units per day (1 unit = 1 hour) per North Carolina state regulations

North Carolina - Professional (CMS-1500) ExceptionsmixedCovered

99509	Daily limit of 96 units per day (state regulation)
A4253	Exempt from MUE (state regulation)
G0155	16 units per day allowed (state regulation)
S9442	4 units per day allowed; 1 unit = 1 hour (state regulation)
A4287	Exempt from MUE (state regulation)
A4238	Exempt from MUE (state regulation)
A4271	Exempt from MUE (state regulation)
A4332	Exempt from MUE (state regulation)

Priority of MUE Application

MUE Application PriorityUnitedHealthcare Community Plan will apply CMS National MUE values first. If no CMS MUE value exists or the CMS MUE is not exceeded, UnitedHealthcare's Maximum Frequency Per Day (MFD) policy will be applied.

Provider Responsibilities and Denial Risk

Documentation Required

Provider documentation & accurate claim submission

You are responsible for submitting accurate claims and ensuring that the code(s) and units billed correctly describe the services provided. Ensure coding and reported units of service are supported by the medical record and other documentation; the policy may be applied with reasonable discretion and may vary by claims system.

Support that the correct code was used
Document that the reported units were performed and medically reasonable and necessary
Be aware processing may vary across claims systems

Denial Risk

Denial risk when units exceed CMS MUE values

If reported units on a claim line exceed the established CMS MUE value for the HCPCS/CPT code, all units on that claim line will be denied; providers may appeal denials when MUE rationale is based on Medicare/Medicaid data.

MUEs define maximum allowable units by provider, patient, date of service — exceeding the MUE causes full line denial
UnitedHealthcare applies CMS MUE values before its own Maximum Frequency Per Day criteria; appeals available where MUE rationale applies

Key Definitions

Medically Unlikely Edit (MUE) — definition and key effects

DefinitionMedically Unlikely Edit (MUE) — the maximum allowable number of units of service by the same provider for the same beneficiary on the same date of service for a claim line.

Consequence of exceedanceFor professional and facility claims, when reported units exceed the established MUE value for the HCPCS/CPT code, all units on the claim line will be denied.

National Correct Coding Initiative (NCCI) — scope and requirements

Inclusion in NCCIThe NCCI methodologies include both Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits (MUEs).

Regulatory requirementSection 6507 of the Affordable Care Act requires State Medicaid programs to implement NCCI-compatible methodologies for correct coding and to control improper payments.

MUE rationale and appealsThe NCCI MUE files include an 'MUE Rationale' column; if the MUE is based on Medicare/Medicaid data, denials may be appealed with supporting documentation.