You’ll receive new message regarding daily quantity maximums

Starting in late March 2014 providers will receive a new message on the provider voucher when a submitted HCPCS or CPT procedure code reaches or exceeds its recommended quantity maximum.

We base our payment — and the member’s liability — on the amount for the eligible quantity. A participating provider should not ask the member to pay more than the amount we allow.

Quantity maximum determines the number of times a procedure can be billed on a single claim line for a particular date. For example, if the quantity maximum is five for a reported HCPCS or CPT code but a quantity of 15 is coded, the message will state that there’s been an adjustment in the reimbursement. Payment will be made for the first five only.

When a maximum quantity is reached, this message will be received: “We can pay for this service, but are limited by our payment policy for this code.  This claim has a quantity that’s more than we can pay.  We based our payment, and the member’s liability, on the amount for the eligible limit.”

Web-DENIS will display claim information with both the allowed quantity and the maximum quantity for the code.