FAQ for MUE Notification
Tikka Attach
Horizon NJ Health
210 Silvia Street
West Trenton, NJ 08628
Phone: (609) 718-9001
horizonNJhealth.com
Independent licensees of the Blue Cross and Blue Shield Association* CMC0010209C
Horizon NJ Health, a product of Horizon HMO*
FAQ for Medically Unlikely Edits (MUE) Notification
Q1. Are there specific edit codes on the Explanation of Payment (EOP) for medically unlikely
edits (MUE)?
A1. Yes, the EOPs will have the denial edit codes listed. Here is the list of denial edits, with
descriptions:
Edit Codes Edit Description
j43
This service is not paid. The procedure exceeded max units
allowed per date of service on this claim for same date of service
(DOS).
j44
This service is not paid. The procedure exceeded max units
allowed per date of service on another claim for same DOS.
j46
The billed quantity exceeded allowed units per DOS. The units
are reduced with appropriate quantity for proper payment.
j68
The MUE has been exceeded for a procedure code, reported by
the same provider, for the same member, on the same date of
service.
l89
The MUE has been exceeded for a procedure code, reported by
the same provider, for the same member, on the same date of
service.
l90
This service is not paid. The procedure exceeded max units
allowed per date of service on this claim for same DOS.
l91
This service is not paid. The procedure exceeded max units
allowed per date of service on another claim for same DOS.
l92
This service is not paid. The procedure exceeded max units
allowed per date of service on this claim or another claim for
same DOS.
l93
The MUE has been exceeded for a procedure code, reported by
the same provider, for the same member, on the same DOS.
l94
This service is not paid. The procedure exceeded max units
allowed per date of service on this claim for same DOS.
l95
This service is not paid. The procedure exceeded max units
allowed per date of service on another claim for same DOS.
l96
This service is not paid. The procedure exceeded max units
allowed per date of service on this claim or another claim for
same DOS.
fb6
The billed quantity exceeded allowed units per DOS. The units
are reduced with appropriate quantity for proper payment.
fc1
The billed quantity exceeded allowed units per DOS. The units
are reduced with appropriate quantity for proper payment.
fc2
This service is not paid. The procedure exceeded max units
allowed per date of service on this claim or another claim for
Horizon NJ Health
210 Silvia Street
West Trenton, NJ 08628
Phone: (609) 718-9001
horizonNJhealth.com
Independent licensees of the Blue Cross and Blue Shield Association* CMC0010209C
Horizon NJ Health, a product of Horizon HMO*
Q2. Where do I find information on the edits?
A2. The EOPs will have the denial edits listed along with the description or reason for denial.
Q3. Which provider types will be affected by the MUE rules?
A3. Professional, durable medical equipment (DME) and outpatient hospital providers.
Q4. What are the MUEs for Medicaid claims?
A4. Medicare Medically Unlikely Edit Practitioner - This edit identifies claim lines where the
MUE has been exceeded for a CPT/HCPCS code with MUE adjudication indicator (MAI) = 1, 2
or 3, reported by the same provider, for the same member, on the same date of service. This edit
will evaluate date ranges to determine if the MUE has been met or not.
Medically Unlikely Edit DME Multiple Lines MCARE Edit- This edit identifies claim lines
where the MUE has been exceeded for a CPT/HCPCS code, reported by the same provider, for
the same member, on the same date of service. This edit audits professional claims regarding
DME supplier services.
Medicare Medically Unlikely Edit Outpatient Hospital Edit - This edit looks at the current
claim line, will check for the quantity billed, and will deny a line quantity over the MUE limit on
outpatient hospital services including emergency hospital services, hospital observation services,
hospital outpatient laboratory services and critical access hospitals. This edit audits facility
claims.
Q5. What dates of service are impacted?
A5. The MCARE MUE rules for practitioners and DME providers/suppliers for Medicaid &
DSNP lines of business are applicable for dates of service on or after October 8, 2017. Claims
with dates of service prior to October 8, 2017 will be excluded from these rules. The MCARE
MUE Outpatient Hospital rules for Medicaid & DSNP lines of business are applicable for dates
of service on or after January 1, 2017. Claims with dates of service prior to January 1, 2017 are
excluded from these rules.
Q6. Can the provider appeal these denials?
A6. Yes, the provider has the right to appeal the denials.
same DOS.
fc3
This service is not paid. The procedure exceeded max units
allowed per date of service on this claim or another claim for
same DOS.
Horizon NJ Health
210 Silvia Street
West Trenton, NJ 08628
Phone: (609) 718-9001
horizonNJhealth.com
Independent licensees of the Blue Cross and Blue Shield Association* CMC0010209C
Horizon NJ Health, a product of Horizon HMO*
Q7. How do I appeal these denials? What process is to be followed?
A7. Section 10.7 of the Horizon NJ Health Provider Administrative Manual provides information
on the Claim Appeals process. To file a claim appeal, a physician or health care professional
must send the appeal application form, which is available at horizonNJhealth.com/for-
providers, and any supporting documentation to Horizon NJ Health using one of the following
methods:
Mail:
Horizon NJ Health
Claim Appeals
PO Box 63000
Newark, NJ 07101-8064
Fax: 1-973-522-4678