Modifier 52

Reimbursement Policy:
Modifier 52

Effective Date:
May 15, 2017

Purpose:
The purpose of this policy is to provide guidelines for the reimbursement of eligible services appropriately appended with Modifier 52 for professional providers.

Definition:
Modifier 52 is used for reporting reduced services when the procedure was terminated after the patient was prepped and was in the room where the service was to be performed.

Scope:
All products are included, except products where Horizon is secondary to Medicare (i.e. Medigap). All Insured and ASO accounts are included.

Policy:
Horizon will reimburse reduced services appropriately appended with modifier 52 at 50% of the applicable Horizon BCBSNJ fee schedule amount. Modifier 52 does not provide for reimbursement of an ineligible service.

Procedure:
Modifier 52, allow at 50% of the applicable Horizon BCBSNJ fee schedule.

No additional reimbursement will be issued if the reimbursement to the physician is via capitation or if reimbursement for such services is captured in a global rate.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member 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

Policy 028_v6.0_01202017