Effective for dates of service beginning May 1, 2026, for our Tufts Health Plan products, we will adopt the maximum unit values established by the Centers for Medicare & Medicaid Services (CMS) and/or Medicaid, when available. This change will align processes for Tufts Health Plan products with existing Harvard Pilgrim processes and promote a consistent provider experience across all Point32Health lines of business. 

Application of medically unlikely edit (MUE) values

Tufts Health Plan will apply and adhere to CMS- and Medicaid-published MUE unit limitations when available.

An MUE represents the maximum number of units of service that may be reported for a specific HCPCS or CPT code on the majority of claims submitted by the same provider or supplier (typically), for the same member, on the same date of service. Please be aware that while this typically applies for codes submitted by the same provider, there are certain cases where the maximum unit policy may be applied whether the service is submitted by the same or different providers. 

Not all codes have an assigned CMS or Medicaid MUE. For codes without a published MUE, Tufts Health Plan will establish a custom unit limit based on code descriptions and historical claim utilization.

Point32Health primarily follows CMS-established MUE values, with certain exceptions based on medical and payment policies, member benefits, state regulations or statutes, or provider contract terms. These exceptions may be more or less restrictive than CMS MUE standards.

Billing and reimbursement/correct coding

No additional reimbursement will be provided for services billed in excess of the applicable CMS or Medicaid MUE value.

For codes without CMS/Medicaid MUEs, claims that exceed Tufts Health Plan’s custom maximum unit value will be denied. Providers may submit an appeal with medical records supporting the necessity of the additional units.

In addition, please keep in mind that MUE values do not override correct coding requirements. Providers must continue to use accurate, complete coding and append appropriate modifiers when needed to distinguish services. Incorrect or incomplete coding may result in frequency denials.

For more information, please refer to our Maximum Units Payment Policy, which we’ve updated to reflect this change.