CurrentAnthemPolicy G-06006

Modifier Usage, Reimbursement Policy

Defines how modifiers must be used on claims submitted to AMH Health (Anthem) for reimbursement, including formatting, documentation requirements, and ordering; applies to providers submitting claims for eligible members.

Policy Summary

PayerAnthem

PolicyModifier Usage, Reimbursement Policy

Policy CodePolicy G-06006

Change TypeNo material changes

Effective DateJan 16, 2024

Next Review Date

Key ActionResubmit corrected claims with the correct modifier and supporting documentation when required to avoid rejection or denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

capital lettersmodifier format requirement

primary fieldmodifier billing location

may requiresupporting documentation

01/16/2024last review

Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

Services are provided to eligible members and billed using appropriate procedure codes and appropriate modifiers when applicable.
Modifiers that affect reimbursement are billed in the primary or first modifier field locator.
Informational modifiers that impact reimbursement are billed in modifier locator fields after reimbursement modifiers, if any.
Informational modifiers that do not impact reimbursement are used for documentation purposes and billed in subsequent modifier field locators.

Policy Summary

PayerAnthem

PolicyModifier Usage, Reimbursement Policy

Policy CodePolicy G-06006

Change TypeNo material changes

Effective DateJan 16, 2024

Next Review Date

Key ActionResubmit corrected claims with the correct modifier and supporting documentation when required to avoid rejection or denial.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding and Modifier Formatting

Modifier formatting and placementModifier

Modifiers must be in capital letters if alpha or alphanumeric; reimbursement modifiers affect payment and must be billed in the primary or first modifier field locator.

Informational modifier orderingModifier

Informational modifiers that impact reimbursement should be billed after reimbursement modifiers; informational modifiers not impacting reimbursement should be billed in subsequent modifier field locators.

Timely Filing Applicability

Timely filing applicabilityCorrected and resubmitted claims are subject to timely filing guidelines.

Resubmission requirementRejected or denied claims must be resubmitted with the correct modifier in conjunction with the code set to be considered for reimbursement.

Modifier format on resubmissionThe modifier must be in capital letters if alpha or alphanumeric when submitting corrected claims.

Provider Actions and Requirements

Documentation Required

Documentation and resubmission requirements

Reimbursement is based on the combination of procedure codes submitted with the correct modifiers. The use of certain modifiers requires the provider to submit supporting documentation along with the claim. Refer to the specific modifier policies for guidance on what documentation to include. AMH Health (Anthem) reserves the right to review adherence to correct coding for high-volume modifiers.

Submit supporting documentation when using modifiers that require it (see specific modifier policies).
Modifiers must be in capital letters when alpha or alphanumeric.
Correct modifier must be billed in conjunction with the appropriate code-set.

Denial Risk

Denial risk for incorrect modifier format

Applicable electronic or paper claims billed without the correct modifier or in an incorrect modifier format may be rejected or denied. Rejected or denied claims must be corrected and resubmitted with the correct modifier and associated code-set to be considered for reimbursement. Corrected and resubmitted claims remain subject to timely filing guidelines. Note that use of the correct modifier does not guarantee reimbursement.

Claims billed without the correct modifier/format risk rejection or denial.
Resubmit corrected claims with the correct modifier in capital letters (if alpha/alphanumeric) and proper code-set pairing.
Corrected/resubmitted claims are subject to timely filing limits.

Definitions

Modifier — Definition

DefinitionModifier: a code element appended to a procedure or service code to indicate that a service has been altered by some specific circumstance but not changed in its definition or code. (See modifier format and billing rules.)

Format requirementModifiers must be submitted in capital letters if alpha or alphanumeric.

Billing placementReimbursement modifiers affect payment and must be billed in the primary or first modifier field locator.

General Reimbursement Policy Definitions — AMH Health

Source of general definitionsGeneral reimbursement policy definitions are provided by AMH Health and published in the policy Definitions section.

PurposeThese definitions guide accurate claims submissions and outline the basis for reimbursement when AMH Health covers the service.

ApplicabilityUnless otherwise noted, reimbursement policies apply to both participating and non-participating professional providers and facilities.