CurrentBlue Cross Blue Shield - MainePolicy C-08010

Modifier Usage - Professional, Commercial Reimbursement Policy

Governance of correct modifier reporting, ordering, and documentation requirements for professional commercial claims submitted to Blue Cross Blue Shield - Maine; applies to providers submitting claims for Anthem members subject to plan and state/federal contract limits.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier Usage - Professional, Commercial Reimbursement Policy

Policy CodePolicy C-08010

Change TypeNo material change

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit supporting documentation with claims when using certain modifiers and ensure modifiers are in capital letters if alpha or alphanumeric.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

capital letters requiredCapitalization

primary/first fieldPlacement

subsequent fieldsInformational modifiers

may be requiredDocumentation

11/26/2024Last update

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyModifier Usage - Professional, Commercial Reimbursement Policy

Policy CodePolicy C-08010

Change TypeNo material change

Effective DateMar 1, 2025

Next Review DateN/A

Key ActionSubmit supporting documentation with claims when using certain modifiers and ensure modifiers are in capital letters if alpha or alphanumeric.

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 billing and adjudication rules

Rules for modifier use, placement, and effects on adjudication.

Modifier must be in 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 in conjunction with the code-set and are subject to timely filing guidelines.

Use of certain modifiers requires the provider to submit supporting documentation with the claim; refer to specific modifier policies for guidance.

Use of correct modifiers does not guarantee reimbursement; reimbursement remains subject to member benefits, authorization, and medical necessity.

The Health Plan reserves the right to review adherence to correct coding for high-volume modifiers and to recoup or adjust payments as necessary.

ALL of the following

Reimbursement modifiers must be billed in the primary or first modifier field locator.
Informational modifiers that impact reimbursement should be billed in modifier locator fields after reimbursement modifiers, if any.
Informational modifiers that do not impact reimbursement should be billed in subsequent modifier field locators; the payer may reorder modifiers to reimburse correctly.

Providers should consult related modifier-specific policies for detailed treatment of individual modifiers and documentation requirements.

Modifier Categories, Placement, and Formatting

Modifier categories and placementModifier

Reimbursement Modifiers	Reimbursement modifiers affect payment and denote circumstances when an increase or reduction is appropriate for the service provided. The modifiers must be billed in the primary or first modifier field locator.
Informational Modifiers Impacting Reimbursement	Informational modifiers determine if the service provided will be reimbursed or denied. Modifiers that impact reimbursement should be billed in modifier locator fields after reimbursement modifiers, if any.
Informational Modifiers Not Impacting Reimbursement	Informational modifiers are used for documentation purposes. Modifiers that do not impact reimbursement should be billed in the subsequent modifier field locators. The payer reserves the right to reorder modifiers to reimburse correctly for services provided.

Modifier formatting requirement — capital letters

Modifier formatting requirementModifiers must be in capital letters if alpha or alphanumeric.

Claim consequencesElectronic or paper claims billed without the correct modifier format may be rejected or denied and must be resubmitted with the correct modifier and code-set.

Resubmission rulesCorrected and resubmitted claims are subject to timely filing guidelines.

Documentation linkageUse of certain modifiers requires submission of supporting documentation with the claim; refer to specific modifier policies for details.

No guarantee of paymentCorrect modifier use does not guarantee reimbursement; payment remains subject to member benefits, authorization, and medical necessity.

Documentation, Authorization, and Submission Requirements

Documentation Required

Documentation and Authorization — certain modifiers require submission of supporting documentation with the claim; adherence to authorization and medical necessity rules

The Health Plan allows reimbursement for covered services provided to eligible members when billed with appropriate procedure codes and appropriate modifiers when applicable. Reimbursement is based on the code-set combinations submitted with the correct modifiers. The use of certain modifiers requires the provider to submit supporting documentation along with the claim — refer to specific modifier policies for guidance on what documentation to include. We reserve the right to review adherence to correct coding for high‑volume modifiers.

Applicable electronic or paper claims billed without the correct modifier in the correct format may be rejected or denied.
Modifiers must be submitted in CAPITAL letters if alpha or alphanumeric.
Rejected or denied claims must be resubmitted with the correct modifier in conjunction with the code‑set to be considered for reimbursement; corrected and resubmitted claims are subject to timely filing guidelines.
The use of correct modifiers does not guarantee reimbursement.

General Definitions

Definitions (general)

Definitions referenceGeneral Reimbursement Policy Definitions (see policy definitions section).

Reimbursement basisReimbursement is based on the code-set combinations submitted with the correct modifiers.

Provider responsibilityProviders must submit supporting documentation when required by certain modifiers.

Right to reviewThe Health Plan reserves the right to review adherence to correct coding for high-volume modifiers and recoup payments if appropriate.

Claim format impactClaims billed without correct modifiers or format may be rejected or denied and require resubmission.

OpenPayer

Modifier Usage - Professional, Commercial Reimbursement Policy

Modifier Billing and Adjudication Rules

Modifier Categories, Placement, and Formatting

Documentation, Authorization, and Submission Requirements

General Definitions