Oscar Health modifier reimbursement policy update | OpenPayer
CurrentOscar HealthPolicy N/A
Modifier Guidelines
Defines Oscar Health's use of CPT/HCPCS/ICD-10 modifiers for determining reimbursement eligibility and explains common modifiers and when services with modifiers may be ineligible for payment. Applies to providers submitting claims to Oscar.
Policy Summary
PayerOscar Health
PolicyModifier Guidelines
Policy CodePolicy N/A
Change TypeAdministrative clarificationsnew policy development approved
Effective Date01/23/2024
Next Review Date03/2026
Key ActionEnsure appropriate modifiers are reported on claims; services billed with inappropriate or missing modifiers will not be eligible for reimbursement.
modifiers; Removed statement from rationale section as it was redundant with policy section; Relocated statement from coding section into policy section
New Policy Development: Reimbursement Governance Committee Approved.
01/23/2024Origination
03/27/2025Last review
03/2026Next review
multipleModifiers listed
10d / 2w
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Duplicate fracture window
TCTC non-reimbursed
Modifier Coverage and Reimbursement Rules
Coverage criteria related to modifier use
Oscar requires appropriate modifier use for reimbursement and will deny payment when modifiers are inappropriate or missing.
Reimbursement for a procedure code/modifier combination will be considered only when the modifier has been used appropriately in accordance with correct coding principles defined by ICD-10, HCPCS and CPT.
When services are billed with inappropriate modifiers or the lack of an appropriate modifier according to our policy, the service will not be eligible for reimbursement.
Anesthesia modifiers (AA, AD, GC, QK, QX, QY, QZ) must be reported with general anesthesia services; general anesthesia CPT codes 00100-01969 will be denied if billed without an appropriate anesthesia modifier.
Modifier 91 (repeat clinical diagnostic laboratory test) is eligible for reimbursement only when billed by a provider with the appropriate specialty designation (Laboratory/Pathology).
Telemedicine modifiers (e.g., 93, 95, GT/GP where noted) designate telemedicine services; refer to the Services Delivered via Telemedicine policy for detailed billing guidance.
Certain modifiers (e.g., PA, PB, PC) that indicate Never Events are not considered reimbursable services.
Specific services (for example PET scans) require designated modifiers (e.g., PI or PS) to be considered reimbursable.
CMS-established subsets of modifier 59 (XE, XP, XS, XU) are more detailed descriptions of modifier 59; appending both 59 and any of XE/XP/XS/XU on the same claim line is not appropriate and will render the line ineligible for reimbursement.
Modifier reimbursement and denial criteria
Oscar Health reimbursement rules for modifiers and situations when services will be denied or not reimbursed:
General anesthesia services (CPT 00100-01969) will be denied if billed without an appropriate anesthesia modifier (AA, AD, GC, QK, QX, QY, QZ).
Anesthesia modifiers should only be appended to anesthesia services; report the appropriate anesthesia modifier to indicate personal performance, medical direction, supervision, or CRNA status.
Modifier JZ must not be reported with a multi-dose vial or package or in conjunction with modifier JW.
Oscar does not reimburse the technical component (TC) when billed separately from the facility claim for services performed in a facility place of service.
Any code appended with modifier 59 in addition to XE, XP, XS, or XU on the same claim line will not be eligible for reimbursement per CMS guidance adopted here.
Modifier and Code Examples
Common CPT/HCPCS modifiers (examples)mixed
22
Increased Procedural Services
24
Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
25
Significant, Separately Identifiable E/M Service by Same Physician
26
Professional Component
50
Bilateral Procedure
59
Distinct Procedural Service (note: CMS has XE/XP/XS/XU subsets)
91
Repeat Clinical Diagnostic Laboratory Test
95
Synchronous Telemedicine via Audio and Video
AA
Anesthesia services performed personally by anesthesiologist
QX
CRNA service: with medical direction by a physician
1–10 of 11
1/2
Relevant modifiers and usageModifier
AA, AD, GC, QK, QX, QY, QZ
Anesthesia modifiers required to indicate medical direction/supervision/CRNA status
XE, XP, XS, XU
Modifiers denoting distinct encounters/practitioners/structures/nonoverlapping services; should not be used with modifier 59 on same claim line
TC
Technical component; Oscar does not reimburse technical component billed separately from facility claim when performed in facility
RR
Rental DME modifier — use when DME is rented; capped rental DME must be appended with RR
RT, LT, RI, SL, SS, TA-T9
Anatomic/site and special purpose modifiers (right/left, anatomic toes, state-supplied vaccine, home infusion suite)
54, 55, 76, 77, 78, 79
Modifiers to indicate surgical/postoperative/related/unrelated or repeat procedures for fracture coding exceptions
inv-05: Anesthesia modifier requirement — general anesthesia services will be denied if billed without an appropriate anesthesia modifier.
Policy requirementGeneral anesthesia services (CPT 00100-01969) must be reported with an appropriate anesthesia modifier (AA, AD, GC, QK, QX, QY, QZ); services will be denied if billed without one.
Append only to anesthesia servicesAnesthesia modifiers should only be appended to anesthesia services; inappropriate service modifiers appended to an anesthesia code may make the service ineligible for reimbursement.
Examples of anesthesia modifiersAA (performed personally by anesthesiologist); AD (medical supervision >4 concurrent cases); QK/QX/QY/QZ (CRNA/medical direction distinctions); GC (service performed in part by resident under teaching physician).
inv-06: fracture duplicate window — timeframes for presumed duplicate fracture care billing (10 days / 2 weeks).
Identical fracture code window
Billing Actions and Denial Risk — What Providers Must Do
Billing Rule
Modifier use determines reimbursement eligibility
When services are billed with inappropriate modifiers or without an appropriate modifier according to this policy, the service will not be eligible for reimbursement. Reimbursement for a procedure code/modifier combination is considered only when the modifier has been used appropriately in accordance with correct coding principles defined by ICD-10, HCPCS and CPT.
Billing Rule
Provider billing actions to avoid denial for anesthesia and modifier conflicts
Report appropriate anesthesia modifiers (AA, AD, GC, QK, QX, QY, QZ) with general anesthesia services and append anesthesia modifiers only to anesthesia services; general anesthesia (CPT 00100-01969) will be denied if billed without an appropriate anesthesia modifier. Do not report modifier JZ with a multi-dose vial or in conjunction with modifier JW. Additionally, do not append modifier 59 on the same claim line as XE/XP/XS/XU per CMS guidance.
Anesthesia modifiers should only be appended to anesthesia services.
Modifier and Coding Definitions
inv-09: Definition of 'Modifier' — explanation of what a modifier reports about a service.
DefinitionA modifier reports that a performed service or procedure was altered by a specific circumstance without changing its definition or code.
Authoritative sourcesDefinition aligns with AMA and CMS guidance noting modifiers indicate altered circumstances but not a changed procedure code.
PurposeModifiers inform payers and auditors about situational details that affect claim processing and reimbursement determinations.
Professional vs technical componentsModifiers may indicate a professional or technical component was performed (e.g., 26/TC distinctions).
Policy Summary
PayerOscar Health
PolicyModifier Guidelines
Policy CodePolicy N/A
Change TypeAdministrative clarificationsnew policy development approved
Effective Date01/23/2024
Next Review Date03/2026
Key ActionEnsure appropriate modifiers are reported on claims; services billed with inappropriate or missing modifiers will not be eligible for reimbursement.
Fracture/dislocation care billed in the office: if the identical code was billed by any provider in the past 10 days, the later claim is assumed duplicative and will be denied; if a different fracture care code was billed in the previous 2 weeks, the later code is presumed post-operative and will be denied unless an appropriate modifier indicating an unrelated or exception circumstance is appended (54, 55, 76, 77, 78, 79).
Use modifier RR to indicate capped rental DME when the item is rented; vaccines and toxoids provided at no cost by the state (e.g., SL) are not eligible for reimbursement.
If the same fracture/dislocation care code was billed by any provider in the past 10 days, a subsequent same-code office billing is presumed duplicative and will be denied.
Different fracture code windowIf a different fracture care code is billed in the office within the previous 2 weeks, it is presumed post‑operative and will be denied unless an appropriate modifier indicates the service is unrelated.
Allowed modifiers for exceptionsModifiers that may indicate unrelated or distinct billing include: 54, 55, 76, 77, 78, 79; note that modifier 54 is not appropriate for closed treatment without manipulation in the ED.
Modifier JZ must not be reported with a multi-dose vial or in conjunction with modifier JW.
Any code appended with 59 in addition to XE, XP, XS, or XU on the same claim line will not be eligible for reimbursement.
Bilateral proceduresModifiers can denote bilateral procedures when applicable.
Distinct/separate services and multiple providers/locationsModifiers indicate distinct or separate services and when procedures were performed by more than one physician or at more than one location.
Increased/reduced, add-on, repeated, site-specific, partial, unusual eventsModifiers signal increased/reduced services, add‑ons, repeated services, specific site/partial services, and unusual events affecting a procedure.
inv-11: Technical Component (TC) — note about TC billing and facility claim handling.
TC meaningTC designates the technical component of a service when the technical component is separately reportable.
Facility billing impactOscar does not reimburse the technical component (TC) when billed separately from the facility claim for services performed in a facility place of service.
Usage noteWhen the technical component is separately reportable, append modifier TC to the procedure code to identify it.
inv-12: XE/XP/XS/XU — CMS guidance that these distinct modifiers should not be used on the same line with modifier 59.
CMS guidance on distinct modifiers vs 59CMS considers XE/XP/XS/XU to be more detailed descriptions of modifier 59; appending 59 in addition to XE/XP/XS/XU on the same claim line will make the code ineligible for reimbursement.
XE = separate encounterXE denotes a service distinct because it occurred during a separate encounter.
XP/XS/XU definitionsXP = separate practitioner; XS = separate structure; XU = unusual nonoverlapping service (does not overlap usual components).
inv-13: Anesthesia modifiers (AA/AD/GC/QK/QX/QY/QZ) — denote personal performance, direction, supervision, or CRNA status.
Modifier set for anesthesiaAA, AD, GC, QK, QX, QY, QZ are the appropriate anesthesia modifiers to denote personal performance, medical direction, supervision, or CRNA status.
AA descriptionAA indicates anesthesia services performed personally by an anesthesiologist.
QX/QZ/QK distinctionsQX (CRNA with medical direction), QZ (CRNA without medical direction), QK (medical direction of 2–4 concurrent anesthesia procedures); AD indicates medical supervision of >4 concurrent cases.
RR meaningRR is the Rental DME modifier and is used when durable medical equipment is to be rented.
Capped rental DMECapped rental DME must be appended with modifier RR.
Site-specific noteAnatomic/site-specific modifiers (e.g., RT, LT) are used to identify separate anatomic sites; RR is distinct for rental DME reporting.