SUBJECT: Medically Unlikely Edits (MUEs)

Transmittal 617, dated January 8, has been rescinded and replaced with Transmittal 652, dated March 17. Transmittal 652 provides the following clarification:

• Clarifies the reference to the manual section authorizing medically unlikely edits (MUEs)
• Clarifies the name of files for the final durable medical equipment (DME) list of MUEs and provides the denial reason code to be used for MUE denials

The Centers for Medicare & Medicaid Services (CMS) developed the MUE program in 2006. MUEs are designed to reduce errors due to clerical entries and incorrect coding. The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs. With regard to MUEs, providers are reminded of the following:

• An appeal process will not be allowed for return to provider (RTP) claims as a result of an MUE. Instead, providers should determine why the claim was returned, correct the error, and resubmit the corrected claim.
• Providers may appeal MUE criteria by forwarding a request the carrier or the Medicare administrative contractor (A/B MAC) who, if they agree, will forward the appeal to the national correct coding contractor.
• Excess charges due to units of service greater than the MUE may not be billed to the beneficiary (this is a “provider liability”), and this provision can neither be waived nor subject to an advanced beneficiary notice (ABN).