May 5, 2014
Last Revised Date:
September 24, 2018
This policy provides guidelines for services appended with modifier SU for participating and nonparticipating professional providers.
All products are included, except:
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
- SHBP Medicare Advantage PPO
- Professional claims with a date of service prior to 05/26/2014
- SHBP claims prior to implementation date
- Professional claims outside the office
- Claims that do not contain Modifier SU
- Facility claims
- Par other
- ITS Home Par
- ITS Host Medicare Advantage Non PPO
- ITS Host Medicare Advantage Non Par
- ITS Host Medigap
- ITS Host Medicaid
- Labor Accounts (OON providers MPL and Flexlink)
All Insured and Administrative Services Only (ASO) accounts are included.
Modifier SU denotes the use of the facility and equipment for a procedure performed in a physician’s office.
The Centers for Medicare and Medicaid Services (CMS) indicates that modifier SU is not payable because CMS has established Relative Value Units (RVU) for CPT and HCPCS codes that include the costs associated with running an office, known as the practice expense RVU.Consistent with the approach taken by CMS, Horizon BCBSNJ reimburses its providers for procedures performed in their offices in a manner which takes into account the costs associated with running an office (ie. overhead, etc.), and as such, Horizon BCBSNJ shall not reimburse separately for services appended with modifier SU.
Deny all service lines on a professional claim that are appended with modifier SU.
In denied instances where the provider is participating, there shall be no member liability.
In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
- Mandated or legislative required criteria will always supersede
7/2014: Policy approved
7/21/2015: Revised Current State, Scope, Policy, Procedure; Added definitions
8/17/2017: Added SHBP Medicare Advantage PPO to Scope exceptions.
09/24/2018: Revisions to Policy section to provide clarity