US · guidance
CMS Pub. 100-04, ch. 1, § 140.1
Threshold Edit for Outpatient and Inpatient Part B Claims
Effective for claims received on or after January 1, 2006, intermediaries shall edit for
outpatient and inpatient Part B claims that meet or exceed a reimbursement amount of
$50,000. The edit shall be applied to the following providers and bill types:
Provider Type Types of Bills
• Hospitals
12X, 13X, 14X
• Skilled Nursing Facilities 22X,
23X
• Home Health Agencies
32X, 33X, 34X
• Religious Nonmedical Health Care Institutions 43X
• Rural Health Clinics
71X
• Renal Dialysis Facilities
72X
• Federally Qualified Health Centers 73X
• Outpatient Rehabilitation Facilities 74X
• Comprehensive Outpatient Rehabilitation Facilities 75X
• Community Mental Health Centers 76X
• Hospice Providers
81X, 82X
• Non-OPPS Hospitals Ambulatory Surgery 83X
• Critical Access Hospitals
85X
The FIs shall suspend those claims receiving the threshold edit for development and
contact providers to resolve billing errors. If the FI determines that the reimbursement is
excessive and claim corrections are required, the FI shall return the claim to the provider.
If the FI determines that the billing is accurate and the reimbursement is not excessive,
the FI shall override the edit and submit the claim to the Common Working File (CWF)
History
(Rev. 620, Issued: 07-29-05, Effective: 01-03-06, Implementation: 01-03-06)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
8de5e47e2ae6fabd7deffc4b9a5bd8dee19916d3baefaf7da90f2ef638e8e06f
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