CurrentBlue Cross Blue Shield - MainePolicy G-20001

Modifier 90

This reimbursement policy governs billing and reimbursement when Modifier 90 is appended for laboratory services, specifying that pass-through billing in an office place of service (11) is generally not allowed and reimbursement is made to the performing laboratory/provider. It applies to Anthem Blue Cross and Blue Shield lines including Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 90

Policy CodePolicy G-20001

Change TypeNo material changes (review approved)

Effective Date07/21/2025

Next Review Date

Key ActionDo not append Modifier 90 for pass-through billing in an office place of service (11); such claims will not be eligible for reimbursement unless required by contract or regulation.

SourceLink

POLICY UPDATE CHANGES

07/21/2025 - Review approved and effective: no changes

07/07/2023 - removed Reference (Outside) Laboratory and Pass-Through Billing from policy title

11/30/2021 - policy language (clarification) and definition updated

100%Reimbursement to performing provider

07/21/2025Last Approval / Effective

G-20001Document ID

Coverage and Reimbursement Criteria

Modifier 90 coverage criteria

Coverage and reimbursement rules for claims appended with Modifier 90:

ALL of the following

Office place of service (11)
- Modifier 90 appended in office place of service (11) — claims will not be eligible for reimbursement unless provider, state, federal, or CMS contracts/requirements indicate otherwise.
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.
Policy does not apply to claims submitted from laboratory and pathology providers that are allowed to bill in an office place of service (11).

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier 90

Policy CodePolicy G-20001

Change TypeNo material changes (review approved)

Effective Date07/21/2025

Next Review Date

Key ActionDo not append Modifier 90 for pass-through billing in an office place of service (11); such claims will not be eligible for reimbursement unless required by contract or regulation.

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.

Modifier & Coding Guidance

Modifier and coding guidanceModifier

Modifier 90

Identifies laboratory procedures performed by a party other than the treating or reporting physician or qualified healthcare professional.

Billing compliance

Billing compliance requirementServices must meet authorization and medical necessity guidelines and be billed with appropriate CPT/HCPCS/revenue codes fully supported in the medical record or office notes.

Coding standardsUse industry-standard, compliant codes (CPT®, HCPCS, and/or revenue codes) on all claim submissions unless otherwise noted in policy.

Potential payer actions for noncomplianceIf coding/billing guidelines or reimbursement policies are not followed, Anthem may reject or deny the claim, recover/recoup payment, or adjust reimbursement to reflect appropriate services performed.

ApplicabilityReimbursement policies apply to both participating and non-participating professional providers and facilities unless otherwise noted.

Overrides and mandatesThese policies may be superseded by provider, state, federal, or CMS contracts and/or requirements; in such cases, those mandates take precedence.

Billing and Reimbursement Directives

Billing Rule

Do not use Modifier 90 for pass‑through billing in POS 11 — reimbursement goes to performing laboratory

Do not append Modifier 90 for pass‑through billing in an office place of service (11); claims with modifier 90 in POS 11 will not be eligible for reimbursement unless provider, state, federal, or CMS contracts/requirements indicate otherwise. 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.

Exceptions: policy does not apply to claims submitted from laboratory and pathology providers allowed to bill in an office place of service (11).
Services must meet authorization and medical necessity guidelines and be billed with appropriate CPT/HCPCS/revenue codes fully supported in the medical record.

Key Definitions

Modifier 90

Modifier 90 definitionWhen laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional, the procedure may be identified by adding modifier 90 to the usual procedure number.

Use caseIdentifies laboratory procedures performed by an outside laboratory or third party rather than the reporting/treating provider.

Relation to reimbursementModifier 90 may be used to indicate third‑party performance; reimbursement rules and beneficiary coverage remain subject to policy criteria and payer contracts.

Pass-Through Billing

Pass-through billing definitionWhen a provider pays a laboratory to perform their tests and then files the claims as though they had performed the tests themselves.

Policy stance on pass-through in POS 11Pass-through billing in an office place of service (11) is not allowed per this policy; reimbursement is paid to the performing laboratory/provider unless superseded by provider, state, federal, or CMS requirements.

Reimbursement destinationReimbursement is made directly to the provider who performed the clinical diagnostic laboratory test per applicable fee schedule or contracted/negotiated rate.