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Claim Editing Update: MUEs for Professional Claims

Effective May 27, 2020, Horizon BCBSNJ will follow Centers for Medicare & Medicaid Services (CMS) guidelines in regard to the maximum number of units of service allowable for certain HCPCS/CPT codes for services rendered by the same provider for the same member on the same date of service.

This update will impact professional claims for services provided to members enrolled in Horizon BCBSNJ commercial and Administrative Services Only (ASO) plans. (The CMS frequency-related claim edits are already applied to claims processed for members enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans.)

Horizon BCBSNJ uses guidelines from different sources to help ensure that our code and claim editing rules are accurate and consistent with standard business practice:

  • We work with Change Healthcare, and use Change Healthcare’s ClaimsXten, a clinically based claims-editing solution.
  • We also follow the guidelines of nationally recognized sources, such as the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (CCI), Outpatient Code Editor (OCE), American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases Clinical Modification (ICD-CM).

While our claim processing system will continue to apply ClaimsXten service frequency maximums (to those HCPCS/CPT codes where they exist in ClaimsXten), beginning May 27, 2020 we will apply CMS MUE guidelines to those HCPCS/CPT codes for which ClaimsXten does not include service frequency maximums.

The CMS MUE guidelines we will follow identify claim lines where the MUE has been exceeded for a CPT/HCPCS code with MUE adjudication indicator (MAI) of 1, 2 or 3, reported by the same provider, for the same member, on the same date of service. Date ranges will be evaluated to determine if the MUE has been met or not as part of MUE guidelines.

For more information about MUEs, please visit CMS’s National Correct Coding Initiative Edits page and review the NCCI Policy Manual for Medicare Services, Chapter 1, Section V (Medically Unlikely Edits).

CPT® is a registered trademark of the American Medical Association.

Published on: February 26, 2020, 01:16 a.m. ET
Last updated on: March 11, 2022, 04:44 a.m. ET