CurrentEmpire BluecrossPolicy C-08010

Modifier billing and reimbursement rules

Defines how modifiers (billing modifiers and informational modifiers) affect claims adjudication and reimbursement for professional commercial providers under Empire Bluecross' commercial reimbursement policies.

Policy Summary

PayerEmpire Bluecross

PolicyModifier billing and reimbursement rules

Policy CodePolicy C-08010

Change TypeRevised modifier classification

Effective DateJun 3, 2025

Next Review DateN/A

Key ActionSubmit required supporting documentation when billing modifiers; claims without correct modifiers may be rejected or denied and must be resubmitted following timely filing guidelines.

SourceLink

POLICY UPDATE CHANGES

Removed modifier QZ from Informational Modifiers list and added to Modifiers Impacting Adjudication list due to a 15% reduction.

15%payment reduction associated with modifier QZ after policy change

06/03/2025policy effective date for current version

C-08010internal policy identifier

Modifier Adjudication and Coverage Rules

Modifier adjudication and coverage rules

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.

Reimbursement is allowed for covered services when billed with appropriate procedure codes and appropriate modifiers, subject to member benefits, authorization, and medical necessity.

See policy scope and authorization requirements.

Modifiers must be submitted in the correct format (capital letters, alpha or alphanumeric) and in the appropriate modifier field locators; reimbursement modifiers must be billed in the primary/first modifier field locator.

Use of certain modifiers requires submission of supporting documentation; claims submitted without required modifiers or without required documentation may be rejected or denied and must be resubmitted following timely filing guidelines.

Informational modifiers are classified by whether they impact reimbursement; those that impact reimbursement should be billed in modifier locators after reimbursement modifiers; informational modifiers that do not impact reimbursement are for documentation and should be billed in subsequent modifier locators. The payer may reorder modifiers to adjudicate correctly.

The payer reserves the right to review, recover/recoup payments, reject or deny claims, and to implement policy updates retroactively in accordance with contracts and law.

Operational change: modifier QZ was moved from informational to impacting adjudication and now results in a 15% payment reduction when applied.

Material policy change effective 06/03/2025.

Modifier Classification and Billing Fields

Modifier classificationsmixed

Modifiers (general)

Modifiers must be billed in the proper modifier fields; reimbursement modifiers affect payment and informational modifiers may or may not impact reimbursement depending on classification.

Reimbursement Modifiersmixed

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 Reimbursementmixed

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 Reimbursementmixed

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. Payer reserves the right to reorder modifiers to reimburse correctly for services provided.

Modifier field / billing order requirements

Primary modifier field requirementReimbursement modifiers must be billed in the primary or first modifier field locator.

Subsequent modifier fieldsInformational modifiers (impacting and not impacting reimbursement) should be billed in modifier fields after reimbursement modifiers or in subsequent modifier field locators.

Modifier formatModifiers must be in capital letters and may be alpha or alphanumeric; incorrect format may lead to rejection or denial.

Corrected claimsClaims billed without correct modifiers must be resubmitted with the correct modifier and are subject to timely filing guidelines.

Authorization, Documentation, and Claim Resubmission

Prior Authorization

Obtain required authorizations and confirm medical necessity

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence. Ensure services meet member benefits, authorization, and medical necessity before submission to avoid denial or recovery of payment.

Documentation Required

Document modifiers and resubmit corrected claims as required

Certain modifiers require submission of supporting documentation. Claims billed without the correct modifier in the correct format may be rejected or denied and must be resubmitted; corrected and resubmitted claims are subject to timely filing guidelines.

Submit supporting documentation when using modifiers that require it.
Ensure modifiers are in capital letters and alpha or alphanumeric format and billed in the proper modifier field.
Resubmit rejected or denied claims with the correct modifier and code-set; follow timely filing rules.

Modifier Definitions and Categories

Reimbursement Modifiers

DefinitionReimbursement modifiers affect payment and denote circumstances when an increase or reduction is appropriate for the service provided.

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

Documentation requirementUse of certain reimbursement modifiers requires submission of supporting documentation as indicated by the policy.

AdjudicationReimbursement is based on code-set combinations submitted with the correct modifiers; correct modifier use does not guarantee payment.

Informational Modifiers

Informational (impacting) modifiersModifiers that determine if the service will be reimbursed or denied; these should be billed in modifier locator fields after reimbursement modifiers.

Informational (not impacting) modifiersModifiers used for documentation only that do not impact reimbursement; bill these in subsequent modifier field locators.

Payer reorderingThe payer reserves the right to reorder modifiers to reimburse correctly for services provided.

Billing order impactInformational modifiers must follow reimbursement modifiers in the modifier sequence so adjudication can be applied correctly.