CurrentHighmark Blue Cross Blue Shield WnyPolicy G-20001

Pass-through billing for laboratory services (Modifier 90)

Governs reimbursement and billing for laboratory services billed with modifier 90 for specified Highmark BCBS New York programs (MMC, HARP, CHPlus, EP) and affects providers submitting claims for clinical diagnostic laboratory tests.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyPass-through billing for laboratory services (Modifier 90)

Policy CodePolicy G-20001

Change TypeClarification / Administrative updates (no material changes)

Effective Date7/21/2025

Next Review Date

Key ActionDo not append modifier 90 for pass-through billing in office POS (11); biller must ensure proper billing to avoid rejection, denial, or recovery.

SourceLink

POLICY UPDATE CHANGES

Policy language and definition updated.

Removed Reference (Outside) Laboratory and Pass-Through Billing from policy title.

07/21/2025 review approved and effective: no changes.

100%reimbursement to performing provider

Not eligibleOffice POS 11 modifier 90

G-20001policy id

07/21/2025effective

Laboratory Pass-Through Billing Criteria

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyPass-through billing for laboratory services (Modifier 90)

Policy CodePolicy G-20001

Change TypeClarification / Administrative updates (no material changes)

Effective Date7/21/2025

Next Review Date

Key ActionDo not append modifier 90 for pass-through billing in office POS (11); biller must ensure proper billing to avoid rejection, denial, or recovery.

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.

Laboratory pass-through billing criteria

Covered when ALL of the following criteria are met:

The health plan does not allow pass-through billing for laboratory services; claims appended with modifier 90 in an office place of service (11) are not eligible for reimbursement unless overridden by provider, state, federal, or CMS contracts/requirements.

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

This policy does not apply to claims submitted from laboratory and pathology providers who are allowed to bill in an office place of service (11).
Provider, state, federal, or CMS contracts and/or requirements that specifically override this policy will supersede these rules.

Failure to follow proper coding and billing guidelines (including use of appropriate CPT/HCPCS/revenue codes and supporting documentation) may result in claim rejection, denial, recovery/recoupment, or adjustment of reimbursement.

Modifier and Place-of-Service Guidance

Modifier guidanceModifierCovered

Modifier 90

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

Place of Service restriction

RestrictionClaims appended with modifier 90 in an office place of service (11) are not eligible for reimbursement unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Reimbursement DirectionReimbursement 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.

ExceptionPolicy does not apply to claims submitted from laboratory and pathology providers allowed to bill in an office place of service (11).

Billing and Authorization Actions for Providers

Denial Risk

Prior authorization & billing risk: Do not append modifier 90 for pass‑through billing in office POS (11)

Do not append modifier 90 to claims billed in an office place of service (11) for pass-through laboratory billing; such 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 at 100% of the applicable fee schedule or contracted/negotiated rate. Ensure proper billing and submission guidelines to avoid claim rejection, denial, recovery, or adjustment of payment.

Modifier 90 appended to claims in office POS (11) are not eligible for reimbursement unless overridden by contracts/requirements. [[CITATION]]
Payments will be made to the performing laboratory at 100% of the applicable fee schedule or contracted rate. [[CITATION]]
Failure to follow billing/submission and coding guidelines may result in claim rejection, denial, recovery, or payment adjustment. [[CITATION]]

Key Definitions

Modifier 90

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

Usage ContextUsed to indicate that the performing laboratory is a party other than the treating or reporting physician or qualified healthcare professional.

Billing ImplicationWhen modifier 90 is appended, reimbursement will follow policy rules regarding pass-through billing and applicable place-of-service restrictions.

Pass-Through Billing

DefinitionPass-through billing occurs when a provider (such as a physician or hospital) pays a laboratory to perform tests and then files claims as though they had performed the tests themselves.

Policy StanceThe health plan does not allow pass-through billing for laboratory services; claims submitted under pass-through billing may be ineligible for reimbursement per policy rules.

Related ActionDo not append modifier 90 for pass-through billing in office place of service (11) unless overridden by provider, state, federal, or CMS contracts/requirements.

OpenPayer

Pass-through billing for laboratory services (Modifier 90)

Laboratory Pass-Through Billing Criteria

Modifier and Place-of-Service Guidance

Billing and Authorization Actions for Providers

Key Definitions

Document Change Log