CurrentbannerhealthandaetnahealthinsurancecompanyPolicy N/A

Important Notice: New York Claim edits for billing modifiers 25, 59 and X series

Customize your policy alerts

Sign up for all bannerhealthandaetnahealthinsurancecompany policy alerts

Know when bannerhealthandaetnahealthinsurancecompany releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

New non-clinical claim-edit procedures apply billing modifier 25, 59, and X series edits to professional and outpatient facility claims for fully insured members in New York; same edits already applied to self-insured membership claims.

Policy Summary

Payerbannerhealthandaetnahealthinsurancecompany

PolicyImportant Notice: New York Claim edits for billing modifiers 25, 59 and X series

Policy CodePolicy N/A

Change TypeExtension of edits to fully insured NY membership claims

Effective DateDec 1, 2020

Next Review DateN/A

Key ActionIf you disagree with an edit, request reconsideration and include a written request with medical records/notes via the EOB address or Availity provider portal; follow normal appeal process if needed.

SourceLink

POLICY UPDATE CHANGES

Effective December 1, 2020, new edits for billing modifiers 25, 59 and X series will be applied in New York for fully insured membership claims.

Dec 1, 2020effective date for edits

3modifier groups targeted (25, 59, X series)

professional & outpatientclaim types subject to edits

self-insuredmembership claims already subject to same edits

Modifier Edit Application

Modifier edit application

Application and nature of edits

Edits apply to claims billed with modifiers 25, 59, and X series.

Effective date: December 1, 2020 for fully insured New York membership claims (these edits already applied to self-insured membership claims).

Scope: Edits are applied prior to finalizing claims for professional services and outpatient facilities.

Nature: Non-clinical claim edits conducted as part of the Third Party Claim and Code Review Program; reviews the claim and submission details to determine if services billed with modifiers 25, 59 and X require separate payment.

Standards: Edits are based on industry-recognized coding guidelines including CMS coverage/payment/coding policies, AMA CPT coding standards, and evidence-based guidelines from professional organizations and public health agencies.

Modifiers and Application Scope

Modifiers subject to new editsModifier

25	Modifier - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
59	Modifier - Distinct procedural service
X	Modifier X{EPSU} series - subsets used as X{EPSU} to indicate distinct procedural service (applicable X modifiers)

Application scope

Application timingEdits are applied prior to finalizing claims for professional services and outpatient facilities

Claim types affectedProfessional services and outpatient facility claims

Membership scopeExtended to fully insured New York membership claims (edits already applied to self-insured membership claims)

Effective dateDecember 1, 2020

Disputes, Reconsideration, and Hospital Options

Prior Authorization

Request reconsideration with written request and medical records

If you disagree with an edit, request a reconsideration in writing and include supporting medical records or clinical notes. Submit your written request and records to the address shown on the EOB, or use the 'Contact us' functionality through the Availity provider portal. If reconsideration does not overturn the edit, you will receive a notice with information about any further appeal rights.

Include a written request plus medical records/notes
Mail to the address on the EOB
Or submit via the Availity provider portal 'Contact us' functionality
If not overturned, a notice will be sent outlining further appeal rights

Documentation Required

Hospital right to submit records under NY § 3224-a

Hospitals may submit medical records when they disagree with coding adjustments under New York Insurance Law § 3224-a. Follow the normal time frames to request a claim reconsideration or appeal unless your contract specifies different dispute provisions.

NY Ins. Law § 3224-a provides hospitals an opportunity to send medical records for disputed coding adjustments
Adhere to normal reconsideration or appeal time frames unless contract states otherwise

Terminology

Third Party Claim and Code Review Program

Program nameThird Party Claim and Code Review Program

PurposeAdministrative program to apply non-clinical coding edits for modifiers 25, 59 and X series

Standards referencedIndustry-recognized coding guidelines (CMS, AMA CPT, evidence-based professional guidelines)

ApplicationEdits applied prior to finalizing claims for professional services and outpatient facilities

Non-clinical claim edit

DefinitionA non-clinical review of the member's claim and submission details to determine whether services billed with modifiers 25, 59 and X require separate payment

Nature of reviewNot a clinical review; determinations are based on coding and submission details

Modifiers targetedModifier 25, Modifier 59, X-series modifiers

OutcomeMay result in coding edits that affect payment, consistent with coding guidelines

Policy Summary

Payerbannerhealthandaetnahealthinsurancecompany

PolicyImportant Notice: New York Claim edits for billing modifiers 25, 59 and X series

Policy CodePolicy N/A

Change TypeExtension of edits to fully insured NY membership claims

Effective DateDec 1, 2020

Next Review DateN/A

SourceLink

On This Page

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.

Important Notice: New York Claim edits for billing modifiers 25, 59 and X series

Customize your policy alerts

Sign up for all bannerhealthandaetnahealthinsurancecompany policy alerts

Know when bannerhealthandaetnahealthinsurancecompany releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Modifier Edit Application

Modifier edit application

Application and nature of edits

Edits apply to claims billed with modifiers 25, 59, and X series.

Effective date: December 1, 2020 for fully insured New York membership claims (these edits already applied to self-insured membership claims).

Scope: Edits are applied prior to finalizing claims for professional services and outpatient facilities.

Modifiers and Application Scope

Modifiers subject to new editsModifier

25	Modifier - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
59	Modifier - Distinct procedural service
X	Modifier X{EPSU} series - subsets used as X{EPSU} to indicate distinct procedural service (applicable X modifiers)

Application scope

Application timingEdits are applied prior to finalizing claims for professional services and outpatient facilities

Claim types affectedProfessional services and outpatient facility claims

Membership scopeExtended to fully insured New York membership claims (edits already applied to self-insured membership claims)

Effective dateDecember 1, 2020

Disputes, Reconsideration, and Hospital Options

Prior Authorization

Request reconsideration with written request and medical records

Include a written request plus medical records/notes
Mail to the address on the EOB
Or submit via the Availity provider portal 'Contact us' functionality
If not overturned, a notice will be sent outlining further appeal rights

Documentation Required

Hospital right to submit records under NY § 3224-a

NY Ins. Law § 3224-a provides hospitals an opportunity to send medical records for disputed coding adjustments
Adhere to normal reconsideration or appeal time frames unless contract states otherwise

Terminology

Third Party Claim and Code Review Program

Program nameThird Party Claim and Code Review Program

PurposeAdministrative program to apply non-clinical coding edits for modifiers 25, 59 and X series

Standards referencedIndustry-recognized coding guidelines (CMS, AMA CPT, evidence-based professional guidelines)

ApplicationEdits applied prior to finalizing claims for professional services and outpatient facilities

Non-clinical claim edit

DefinitionA non-clinical review of the member's claim and submission details to determine whether services billed with modifiers 25, 59 and X require separate payment

Nature of reviewNot a clinical review; determinations are based on coding and submission details

Modifiers targetedModifier 25, Modifier 59, X-series modifiers

OutcomeMay result in coding edits that affect payment, consistent with coding guidelines