CurrentAnthemPolicy G-06006

Modifier Usage for Reimbursement

This policy governs how modifiers must be billed with procedure codes for reimbursement under Anthem Blue Cross and Blue Shield Medicaid (Ohio Medicaid Managed Care) and outlines which modifiers are recognized, informational, or not accepted. It affects providers submitting claims for Medicaid members in the governed state.

Policy Summary

PayerAnthem

PolicyModifier Usage for Reimbursement

Policy CodePolicy G-06006

Change TypeOperational update (clarified modifier lists)

Effective Date01/16/2024

Next Review DateN/A

Key ActionSubmit supporting documentation when required by certain modifiers and ensure modifiers are in capital letters to avoid claim rejection or denial.

SourceLink

POLICY UPDATE CHANGES

Updated Reimbursement Modifiers code list to include related reimbursement policies and removed QY from not recognized modifiers.

01/16/2024policy effective/review date

>=30modifiers not recognized

Ohioapplicability

CMS/defaultfallback guidance

Modifier Billing and Reimbursement Rules

Modifier billing and reimbursement rules

Rules governing modifier use and impact on reimbursement

Reimbursement is allowed when appropriate procedure codes and appropriate modifiers are billed, unless superseded by provider, state, federal, or CMS requirements.

Reimbursement is based on the code set combinations submitted with the correct modifiers; the use of certain modifiers requires providers to submit supporting documentation along with the claim.

Modifiers must be submitted in the correct format: capital letters if alpha or alphanumeric.

Applicable electronic or paper claims billed without the correct modifier in the correct format may be rejected or denied. Rejected or denied claims must be resubmitted with the correct modifier and code set and are subject to timely filing guidelines.

Policy Summary

PayerAnthem

PolicyModifier Usage for Reimbursement

Policy CodePolicy G-06006

Change TypeOperational update (clarified modifier lists)

Effective Date01/16/2024

Next Review DateN/A

Key ActionSubmit supporting documentation when required by certain modifiers and ensure modifiers are in capital letters to avoid claim 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.

Recognized, Informational, and Not-Recognized Modifiers

Modifier Format RequirementModifiers must be entered in CAPITAL letters if alpha or alphanumeric. Claims billed without the correct modifier in the correct format may be rejected or denied. Resubmitted corrected claims are subject to timely filing guidelines.

Informational Modifiers Not Impacting Reimbursement (Not Recognized by Anthem)ModifierNot Covered

22	Unspecified — listed as not recognized by Anthem.
53	Unspecified — listed as not recognized by Anthem.
54	Unspecified — listed as not recognized by Anthem.
55	Unspecified — listed as not recognized by Anthem.
56	Unspecified — listed as not recognized by Anthem.
57	Unspecified — listed as not recognized by Anthem.
63	Unspecified — listed as not recognized by Anthem.
66	Unspecified — listed as not recognized by Anthem.
76	Unspecified — listed as not recognized by Anthem.
77	Unspecified — listed as not recognized by Anthem.

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Reimbursement Modifiers (Related Coding Guidance)Modifier

Guidance

In absence of a modifier-specific reimbursement policy, refer to provider manual and state/federal guidelines for modifiers affecting reimbursement or state/federal payment methodologies.

Documentation, Claim Resubmission, and Billing Requirements

Documentation Required

Documentation and modifier requirements

The use of certain modifiers requires the provider to submit supporting documentation along with the claim; refer to specific modifier policies for guidance. Correct modifiers may also be required for prior authorization and to avoid claim rejection or denial.

Submit supporting documentation when a modifier’s policy specifically requires it.
Check specific modifier policies for documentation requirements used for prior authorization.

Billing Rule

Claim resubmission and timely filing

Claims billed without the correct modifier in the correct format may be rejected or denied; such rejected or denied claims must be resubmitted with the correct modifier and code set and are subject to timely filing guidelines.

Ensure modifiers are in capital letters if alpha or alphanumeric.
Resubmit rejected/denied claims with the correct modifier and associated code set to be considered for reimbursement.
Corrected and resubmitted claims remain subject to timely filing limits.

Related Policies and Modifier Categories

inv-07: Related Policies and Materials

Related modifier policies (examples)Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU); Modifier 22; Modifiers 26 and TC; Modifier 24; Modifiers 25 and 57.

Other related policy topicsDocumentation Standards for Episodes of Care; Duplicate or Subsequent Services on the Same Date of Service; Multiple and Bilateral Surgery (Modifiers 50 and 51).

Clinical/support categories referencedNurse Practitioner and Physician Assistant Services; Professional Anesthesia Services; Portable/Mobile/Handheld Radiology Services.

Administrative topics referencedClaims Timely Filing; Preadmission Services for Inpatient Stays; Provider Preventable Conditions.

Split-care category referencesSplit-Care Surgical Modifiers are referenced in relation to Technology Assisted Surgical Procedures and Transportation Services.

inv-08: Split-Care Surgical Modifiers

Split-Care Surgical Modifiers definitionSplit-Care Surgical Modifiers are associated with categories such as Technology Assisted Surgical Procedures and Transportation Services.

Technology assisted proceduresSplit-care modifiers reference Technology Assisted Surgical Procedures as part of modifier definitions.

Other examplesSplit-Care Surgical Modifiers also reference Transportation Services and Vaccines for Children in the definitions section.