MedicaidCoverageHigh impact
[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·VA · Pathology·Claims & Billing
Effective date
Dec 1, 2026
We identified it
Sep 2, 2026
Summary
HealthKeepers, Inc. (Anthem) is implementing a new combined reimbursement policy (G-20001) effective December 1, 2026, that prohibits reimbursement for professional and outpatient facility claims billed with modifier 90 (pass-through laboratory billing). Providers must bill laboratory services directly to receive reimbursement at 100% of the applicable fee schedule. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and eligible for reimbursement. The previous modifier 91 policy (G-06020) will be retired.
Action Required
By November 30, 2026: Billing team must update all billing software and claims submission workflows to REJECT or FLAG any professional or outpatient facility laboratory claims submitted with modifier 90 for HealthKeepers, Inc. Medicaid plans in Virginia. Providers performing laboratory tests must be instructed to bill services directly using their own provider credentials instead of using pass-through billing with modifier 90. Modifier 91 claims for repeat clinical diagnostic laboratory tests should continue processing per existing guidance. Update billing system to reference new policy G-20001 instead of retired policy G-06020. Communicate this change to all contracted providers and in-house clinical staff performing laboratory services. Document the policy change in all billing procedures and training materials. Failure to comply will result in claim denials and potential overpayment recovery. Staff should not balance bill members based on this policy change.