Upcoming Change to Unlisted Code Review Threshold
March 09, 2026
Effective May 9, 2026, the threshold for manual review of unlisted codes will be updated for all Commercial lines of business (Fully Insured, Under65, Small Group, Large Group, and ASO).
What’s changing
- The dollar threshold that triggers manual review for unlisted codes is decreasing from $400 to $200.
- Any unlisted code with a billed line amount of $200 or more will now be flagged for review.
- This change applies across all Commercial products.
How manual review will work
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Claims meeting the threshold will undergo review for:
- Appropriate clinical documentation
- Correct billing and coding
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Codes will be manually priced under individual consideration.
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This replaces the previous process, in which these codes were allowed to pay at a percentage of billed charges without review.
Why this change is being made
- Ensures more accurate reimbursement for services not associated with a specific CPT/HCPCS code.
- Promotes consistent, appropriate claim adjudication across all Commercial plans.
- Supports clinical and financial integrity efforts.
What providers should do
- Include clear and complete clinical documentation when billing unlisted procedure codes.
- Include unaltered and complete manufacturers’ invoice when billing unlisted DME codes.
- Ensure that billed codes accurately reflect the service performed.
- Expect manual pricing when billed amounts meet or exceed the $200 threshold beginning May 9, 2026.