Exceeds Contracted Maximum Hours/Days/Units for This Provider

What it means

This denial means the payer's contract with the provider sets a limit on how many hours, days, or units of a particular service can be billed within a specific period, and the claim as submitted goes over that limit. It's tied to a contracted cap specific to this provider (not a general payer policy limit), so the same service billed by a different provider under a different contract might not trigger this denial.

Common causes

Billing more units/hours/days of a service than the provider's payer contract allows for the period
Multiple claims for the same patient and service period that collectively exceed the contracted cap
Misunderstanding or outdated information about the specific contracted limits for this provider
Data entry errors resulting in inflated unit counts on the claim
Services rendered across multiple dates being bundled incorrectly, pushing totals over the limit
Contract terms recently changed and the billing team wasn't updated

How to fix it

Pull the actual contract or fee schedule for this provider to confirm the exact maximum hours/days/units allowed for the period in question
Review the claim and any related claims for the same date range to verify the units billed and whether a true overage occurred
Correct and resubmit the claim if the units were entered in error
If the units billed are accurate and medically necessary, gather documentation (medical records, physician notes) showing why the service exceeded typical limits
Contact the payer's provider relations or contracting department to clarify the specific contracted threshold and whether an exception or amendment process exists
Check whether the service should have been split across different billing periods per the contract terms and resubmit accordingly

Appeal / resubmit

When appealing, confirm the exact contracted limit by requesting a copy of the relevant provider agreement section from the payer. Include documentation showing medical necessity for the additional units, such as physician orders, treatment plans, or clinical notes justifying the volume of services. If you believe the payer miscounted units across multiple claims, provide an itemized summary showing how the total was calculated. Note that because this is a provider-specific contracted limit, outcomes can vary depending on individual contract terms and payer discretion.

Related codes

Frequently asked

Does this mean Medicare or a general plan limit was exceeded?

No, code 222 specifically refers to a contracted maximum set between the payer and this particular provider, not a standard benefit or Medicare policy limit.

Can I just resubmit the claim with fewer units?

If the original unit count was an error, correcting and resubmiting with the accurate, contract-compliant number of units may resolve the denial, but you should first confirm the correct contracted limit.

What if the units billed were medically necessary?

You can submit an appeal with supporting clinical documentation, though approval depends on the specific terms of the provider's contract and the payer's review process.

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This content is for general informational purposes only and does not constitute billing, legal, or reimbursement advice. Always verify specifics with the applicable payer contract and guidelines.