May 15, 2017
The purpose of this policy is to provide guidelines for the reimbursement of eligible services appropriately appended with Modifier 53 for professional providers.
Modifier 53 is used to indicate that the physician terminated a surgical/diagnostic procedure due to the patient’s well-being.
All products are included, except products where Horizon is secondary to Medicare (i.e. Medigap)
All Insured and ASO accounts are included.
Horizon BCBSNJ will reimburse discontinued procedures appropriately appended with modifier 53 at 25% of the applicable Horizon BCBSNJ fee schedule amount. Modifier 53 does not provide for reimbursement of an ineligible service.
Modifier 53, allow at 25% 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