Notification of NCCI review of medically unlikely edits

Beginning with dates of service on or after September 1, 2024, Anthem will implement a review of the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Medically Unlikely Edits (MUEs) that have a Medical Adjudication Indicator (MAI) of 3.

Per CMS.gov, an MAI of 3 is defined as “‘per day edits based on clinical benchmarks.’ MUEs assigned an MAI of “3” are based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services.”

“MUE Adjudication Indicator (MAI) of “1” or “3” may pay correctly coded and correctly counted medically necessary UOS more than the MUE value.”

As a result of this review, updates will be made to ensure alignment with NCCI and CMS guidelines, which may result in a claim line denial for services submitted with CMS MUEs with a MAI of 3.

The following reimbursement policies will be updated to align with CMS and NCCI guidelines as follows:

• Code and Clinical Editing — Professional:
• Addition of language stating the health plan will follow procedure to procedure (PTP) edits
• Addition of language stating the health plan will follow CMS MUEs and when a service unit exceeds a CMS MUE, the claim line(s) will be denied
• Frequency Editing — Professional: Removal of drug codes (J codes) from the policy (the removed codes will have limits based on the CMS MUEs)
• Unit Frequency Maximums for Drugs and Biologic Substances — Professional: The policy will be retired (the codes outlined in the policy will align with CMS MUEs)

For specific policy details, visit Provider Reimbursement Policies | Anthem.

If you believe a claim reimbursement decision should be reviewed, please follow the normal claims dispute process outlined in the provider manual and include medical records that clarify whether the procedure or service was medically necessary to exceed the clinical benchmarks and indicate where that specific information can be found in the supporting medical record. You only need to submit the portion(s) of the medical record that is relevant to the billed procedure or service.

If you have questions about this notification, contact your contract manager or provider relationship management representative.