General Question for the Week of June 5, 2017

General Compliance Question of the Week

Question:

Is there an appeal process for units of service (UOS) denied based on medically unlikely edits (MUEs)?

Answer:

UOS denied due to a MUE, whether a claim line MUE or date-of-service MUE, may be appealed. Appeals should be submitted to local contractors, not the MUE contractor. Contractors adjudicating appeals will determine whether:

  • The appropriate HCPCS/CPT code is reported
  • The appropriate number of UOS is reported
  • Whether the UOS reported are medically reasonable and necessary.

Contractors may pay UOS in excess of the MUE value if the contractor determines that they are medically reasonable and necessary.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.