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