Medicare AdvantageReimbursementHigh impact
[Georgia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·AL, CT, GA, IN, KY, ME, MO, NV, NH, NY, OH, VA, WI · Pathology·Claims & Billing
Effective date
Dec 1, 2026
We identified it
Sep 2, 2026
Summary
Effective December 1, 2026, Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) that prohibits reimbursement for laboratory services billed with modifier 90 (pass-through billing). Providers must bill directly for laboratory services and will be reimbursed at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and is consolidated into this new policy. The prior modifier 91 policy (G-06020) is being retired.
Action Required
By November 30, 2026: Billing team must implement the following changes for all Anthem Medicare Advantage claims in affected states: (1) Stop billing laboratory services with modifier 90 immediately—these claims will be denied; (2) Update billing software and encounter forms to flag any modifier 90 laboratory claims for rejection before submission; (3) Retrain billing staff and providers that laboratory services must be billed directly by the performing provider or facility, not as pass-through (modifier 90) claims; (4) Confirm modifier 91 procedures for repeat clinical diagnostic laboratory tests are still eligible for reimbursement at 100% and remain in billing workflows; (5) Retire all references to policy G-06020 in internal documentation and replace with policy G-20001. Note: Pathology services billed with modifier 90 are excluded from this restriction. Failure to comply will result in claim denials for all modifier 90 laboratory services.