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Pass Through Billing (Modifier 90)

Effective Date:
January 1, 2022

Purpose:
This policy outlines our guidelines in regard to the use of Modifier 90 when submitting claims for laboratory tests where the rendering laboratory provider is a reference laboratory, and not the billing laboratory provider or related to the billing laboratory provider.

The guidelines of this policy apply to outpatient or non-patient laboratory tests rendered or billed by all participating and nonparticipating providers, including but not limited to physicians, hospitals, and clinical laboratories.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home Par
  • ITS Home Non Par

Definitions:
Biller - The entity (such as a clinical laboratory, hospital, physician) that bills for the laboratory service

Pass Through Billing - When a physician, hospital or clinical laboratory bills for a laboratory test that was performed by a Reference Laboratory

Reference Laboratory - A laboratory or individual that performs a laboratory test for or on behalf of a biller of a laboratory test that is NOT Related to the reference laboratory.

Related – A reference laboratory is considered “related” to a biller of a laboratory test if:

  • The Reference Laboratory is owned 100% by the Biller of the laboratory test.
  • The Biller of the laboratory test is owned by the Reference Laboratory.
  • The Reference Laboratory and the Biller of the laboratory test are owned by same entity.
  • The Reference Laboratory is an employee of the Biller.

Modifier 90 Reference (Outside) Laboratory - When laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure should be identified by adding modifier 90 to the usual procedure number.

Policy:
Horizon BCBSNJ expects that claims for laboratory tests provided to a member who is not an inpatient to be billed by the laboratory that performs the laboratory test. However if a Reference Laboratory does not bill for a test, the Biller of the laboratory test must identify these Pass Through Billing services by appending Modifier 90 to all bill lines for laboratory services provided by a Reference Laboratory.

Procedure:
Horizon BCBSNJ will review all laboratory service claim lines that are not appended with Modifier 90 to determine if the service should have been appended with Modifier 90.

If it is determined that a laboratory bill line on a newly submitted claim line should have been appended with Modifier 90 but was not, that bill line will be rejected as an incorrect laboratory claim line.

If a finalized laboratory claim audit is performed and it is determined that a particular laboratory claim line should have been appended with Modifier 90, Horizon BCBSNJ may adjust the claim to recover previously reimbursed amounts.