Modifier 90 (Pass-through laboratory billing)
Defines Anthem Blue Cross Medi-Cal Managed Care reimbursement stance for Modifier 90 (pass-through billing) when laboratory services are billed in an office place of service and identifies who may be reimbursed.
07/21/2025 - Review approved and effective: no changes
07/07/2023 - Review approved and effective: removed Reference (Outside) Laboratory and Pass-Through Billing from policy title
11/30/2021 - Review approved and effective: Policy language (clarification) and definition updated
Modifier 90 Coverage Criteria
Modifier 90 coverage criteria
Coverage and payment rules for services billed with Modifier 90.
ALL of the following
- General prohibition: Claims appended with modifier 90 in an office place of service (11) will not be eligible for reimbursement unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.
- Reimbursement to performing provider: Reimbursement will be made directly to the provider who performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate.
- Exception for lab/pathology providers: Policy does not apply to claims submitted from laboratory and pathology providers allowed to bill in an office place of service (11).
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