February 25, 2019
Provide guidelines for the application of modifier 76 when appropriately billed by professional providers.
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- ITS Home In-Network
- SHBP non MA
All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.
ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis
Modifier 76: Used to indicate that a procedure or service was repeated subsequent to the original procedure or service by the same provider ID on for the same member on the same date of service or within the post-operative period.
Horizon BCBSNJ shall consider for reimbursement procedures appended with modifier 76 only in instances where the same procedure is billed by the same provider NPI, for the same member, on the same date of service or within the postoperative period of the original service.
Horizon BCBSNJ shall consider for reimbursement procedures appended with modifier 76 when the same procedure code has been billed by the same Provider TIN or NPI for the same member on the same date of service, or within the post-operative period of the billed procedure. Horizon BCBSNJ shall apply the applicable Horizon BCBSNJ fee schedule to procedures appropriately appended with modifier 76.
Horizon BCBSNJ shall deny procedures appended with modifier 76 when the same procedure code has not been billed by the same Provider TIN or NPI for the same member on the same date of service, or within the post-operative period of the billed procedure.
No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.
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.
11/15/2017: Policy approved