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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAnthem facility modifier policy update | OpenPayer
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    CurrentAnthemPolicy C-23005

    Modifier Usage - Facility, Commercial Reimbursement Policy

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    Defines Anthem's requirements for billing modifiers on facility claims for eligible commercial members, including which modifiers affect reimbursement, documentation expectations, and formatting rules for claims submission.

    Policy Summary
    PayerAnthem
    PolicyModifier Usage - Facility, Commercial Reimbursement Policy
    Policy CodePolicy C-23005
    Change TypeAdded modifiers ER, PN, PO
    Effective DateApr 1, 2026
    Last ReviewNov 12, 2025
    Next Review Date
    Key ActionSubmit supporting documentation when specific modifiers require it; corrected/resubmitted claims must follow timely filing guidelines.
    SourceLink
    POLICY UPDATE CHANGES

    Updated Related Coding list by adding modifiers ER, PN, and PO.

    3modifier types described
    1required modifier format rule
    timely filing applies

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    resubmission rule
    reservedreorder right

    Modifier Billing and Reimbursement Rules

    Modifier billing and documentation rules

    General billing and reimbursement stance for facility modifiers.

    Claims must be billed with appropriate procedure codes and correct modifiers; the use of correct modifiers does not guarantee reimbursement.
    The use of certain modifiers requires the provider to submit supporting documentation with the claim; refer to specific modifier policies for documentation guidance.
    Applicable electronic or paper claims billed without the correct modifier in the correct format may be rejected or denied; modifiers must be in capital letters if alpha or alphanumeric.
    Rejected or denied claims must be resubmitted with the correct modifier and code-set to be considered for reimbursement; corrected and resubmitted claims are subject to timely filing guidelines.
    Reimbursement modifiers affect payment (increase or reduction as appropriate) and must be billed in the primary/first modifier field locator.
    Informational modifiers that impact reimbursement should be billed in modifier locator fields after reimbursement modifiers.
    Informational modifiers that do not impact reimbursement are used for documentation purposes and should be billed in subsequent modifier field locators.

    Plan rights

    • The health plan reserves the right to review adherence to correct coding for high-volume modifiers.
    • Anthem reserves the right to reorder modifiers to reimburse correctly for services provided.
    Providers should follow specific modifier policies for additional details; this policy is not an all-inclusive list of accepted facility CPT and HCPCS modifiers.

    Modifier Categories and Field Placement

    Reimbursement modifiersModifierCovered
    No codes listed
    Informational modifiers impacting reimbursementModifier
    No codes listed
    Informational modifiers not impacting reimbursementModifier
    No codes listed
    Modifier field placement rule — overall
    RuleReimbursement modifiers must be billed in the primary/first modifier field locator; informational modifiers must be billed after reimbursement modifiers or in subsequent modifier fields.
    FormattingModifiers must be submitted in capital letters if alpha or alphanumeric.
    Claim handlingClaims billed without the correct modifier or format may be rejected or denied and must be resubmitted with the correct modifier and code-set for consideration.
    Resubmission timingCorrected and resubmitted claims are subject to timely filing guidelines.
    Plan rightsAnthem reserves the right to review high-volume modifier use and to reorder modifiers to reimburse correctly.

    Modifier Definitions

    Reimbursement modifiers
    DefinitionModifiers that affect payment and denote circumstances when an increase or reduction is appropriate for the service provided.
    PlacementMust be billed in the primary or first modifier field locator.
    ImpactAffects reimbursement amount when paired with procedure codes and code-set combinations.
    DocumentationUse of certain reimbursement modifiers may require supporting documentation to be submitted with the claim.
    Informational modifiers impacting reimbursement
    DefinitionModifiers that determine if the service provided will be reimbursed or denied.

    Documentation, Resubmission, and Billing Actions

    Documentation Required

    Documentation and corrected/resubmitted claim requirements

    Submit supporting documentation when a specific modifier’s policy requires it; refer to the specific modifier policies for guidance on what to include. If a claim is rejected or denied for incorrect or missing modifiers, resubmit the corrected claim with the correct modifier (modifiers must be in capital letters if alpha/alphanumeric) and the associated code-set; corrected/resubmitted claims are subject to timely filing guidelines.

    • Provide supporting documentation with the claim when a modifier’s policy explicitly requires it.
    • Ensure modifiers are in capital letters if alpha or alphanumeric and billed in the correct modifier field per policy.
    • Resubmit rejected or denied claims with the correct modifier and code-set; corrected/resubmitted claims must meet timely filing requirements.
    Policy Summary
    PayerAnthem
    PolicyModifier Usage - Facility, Commercial Reimbursement Policy
    Policy CodePolicy C-23005
    Change TypeAdded modifiers ER, PN, PO
    Effective DateApr 1, 2026
    Last ReviewNov 12, 2025
    Next Review Date
    Key ActionSubmit supporting documentation when specific modifiers require it; corrected/resubmitted claims must follow timely filing guidelines.
    SourceLink
    On This Page
    Modifier Billing and Reimbursement RulesModifier Categories and Field PlacementModifier DefinitionsDocumentation, Resubmission, and Billing Actions
    Placement
    Should be billed in modifier locator fields after reimbursement modifiers, if any.
    Effect on paymentThese modifiers can influence adjudication (reimbursed vs denied) and therefore must be sequenced after reimbursement modifiers.
    Provider actionWhen used, follow any specific modifier documentation guidance referenced in policy.
    Informational modifiers not impacting reimbursement
    DefinitionModifiers used for documentation purposes that do not impact reimbursement.
    PlacementShould be billed in subsequent modifier field locators (after reimbursement and informational-impacting modifiers).
    Plan authorityAnthem reserves the right to reorder modifiers to reimburse correctly for services provided.
    ScopeThese are for documentation and do not change payment determination, but must still follow formatting and submission rules.