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Medicare Part B Electronic Claims that Exceed the Threshold for Charges and Units of Service
Medicare Part B electronic claims (ANSI X12 837P) with total charges exceeding $99,999.99 cannot be processed in the MCS. If a single claim exceeds the threshold charge amount, it will reject/deny.
Units of service cannot exceed 9,999 per line item. If a single claim exceeds the maximum unit threshold, it will reject/deny.
Maximum Charges Allowed $99,999.99
When total charges exceed $99,999.99 for a single date of service follow the guidance below to ensure claims are submitted accurately and do not reject/deny:
- Split the claim – depending on charges this may be two or more claims
- For the same service, procedure, or drug add modifier 76 to the subsequent claim(s)
- Effective on and after 11/6/2023, drug and biological claims missing the required information will be rejected
- For a different service or procedure add modifier 59 to the subsequent claim(s)
- For the same service, procedure, or drug add modifier 76 to the subsequent claim(s)
- Submit all claims for that single date of service at the same time
- Include a comment on each claim, identifying this is a series of claims due to the total charges exceeding the $99,999.99 threshold
- On the 837P electronic submission, enter comments into Loop 2300 or 2400, Segment NTE02
- Sample comments:
- Claim 1 of 2 total charges equal $150,000
- Claim 2 of 2 total charges equal $150,000
Maximum Units Allowed 9,999
When the total units exceed 9,999 for a single line item follow the guidance below to ensure claims are submitted accurately and do not reject/deny:
- Split the claim into sperate line items and/or sperate claims as applicable
- Be mindful to not exceed MUE values
- For the same service, procedure, or drug add modifier 76 to the subsequent claim(s)
- Effective on and after 11/6/2023, drug and biological claims missing the required information will be rejected
- For a different service or procedure add modifier 59 to the subsequent claim(s)
- For the same service, procedure, or drug add modifier 76 to the subsequent claim(s)
- When it is necessary to submit multiple claims
- Submit all claims for that single date of service at the same time
- Include a comment on each claim, identifying this is a series of claims due to the total units exceeding the threshold
- On the 837P electronic submission, enter comments into Loop 2300 or 2400, Segment NTE02
- Sample comments:
- Claim 1 of 2 units exceeding the maximum threshold
- Claim 2 of 2 units exceeding the maximum threshold
For further billing guidance on specific drug/biologicals when the claim/line items exceeds $99,999.99/9,999 visit our Drugs and Biologicals page.
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Revised 10/31/2024