National Correct Coding Initiative (NCCI) – Medically Unlikely Edits Review Process

The Department of Social Services (DSS) is implementing a process for reviewing claims denied solely due to exceeding the National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) limit for dates of service July 1, 2016 and forward. A Medicaid NCCI MUE edit is a unit of service claim edit that defines the number of units of service beyond which the reported number of units of service is unlikely to be correct for certain CPT codes and HCPCS codes. MUEs are based on quarterly NCCI updates received from CMS. Providers can request DSS review of claims with denied details due to exceeding an MUE with Explanation of Benefits (EOB) Code 770 “MUE Units Exceeded”. Claim details over the assigned MUE limit will be denied even if there is an approved prior authorization (PA) that would otherwise allow coverage of the service. If a claim denies solely due to exceeding the NCCI MUE limit, providers may submit a request to have the claim reviewed. An electronic claim must be submitted following the guidelines set forth in Provider Bulletin 2017-49, “Electronic Claim Submission with Paper Attachment Process” for an MUE review. It must list all the services rendered on the denied claim. The detail that exceeded the allowed MUE must be broken out into two separate details. The first detail line should be submitted with the allowed MUE units and the remaining units must be submitted on a separate detail with the GD modifier (Units of service exceeds medically unlikely edit value and represents reasonable and necessary services). The electronic claim will be suspended for review.

Source: https://www.ctdssmap.com/CTPortal/Information/Get Download File/tabid/44/Default.aspx?Filename=PB17_69.pdf&URI=Bulletins/PB17_69.pdf