Medically Unlikely Editing (MUE)

March 29, 2011

Starting April 1st, MaineCare will be implementing Medically Unlikely Edits (MUEs) as mandated by Centers for Medicare and Medicaid Services (CMS) as a part of the National Correct Coding Initiative (NCCI).

Medically Unlikely Edits are based upon the maximum number of units of a service a person could reasonably expect to receive in one day. MUEs will be performed on professional (CMS 1500) claims as well as Outpatient and Critical Access Hospital claims.

Claim lines which deny for MUE will be identified on the Remittance Advice/835 with the following denial reasons:

•Claims Adjustment Reason Code (CARC) 35- Lifetime benefit maximum has been reached.

•Remark Adjustment Reason Code (RARC) N362 - The number of days or units of service exceeds our acceptable maximum.

More information about the MUEs initiative is available on CMS's website .