February 25, 2019
Provide guidelines for the application of modifier 77 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 77: Used to identify when the same procedure has been performed by a different provider to the same member on the same date of service or within the post-operative period of the original procedure.
Horizon BCBSNJ shall consider for reimbursement procedures appended with modifier 77 only in instances where the same procedure is billed by a different 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 77 when the same procedure code has been billed by a different 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 77.
Horizon BCBSNJ shall deny procedures appended with modifier 77 when the same procedure code has not been billed by a different provider TIN or NPI 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
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