Medicare AdvantageReimbursementHigh impact
[Ohio] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·OH · Pathology·Claims & Billing
Effective date
Dec 1, 2026
We identified it
Sep 2, 2026
Summary
Effective December 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage in Ohio is implementing a new reimbursement policy that prohibits pass-through laboratory billing using modifier 90—the performing provider must bill directly for reimbursement at 100% of the applicable fee schedule. Modifier 91 guidance remains unchanged and eligible for reimbursement on repeat clinical diagnostic laboratory tests. The existing modifier 91 policy (G-06020) will be retired and consolidated into the new combined policy (G-20001).
Action Required
By November 30, 2026: Billing team must audit all laboratory service claims currently using modifier 90 to identify pass-through billing scenarios and implement workflow changes to prevent submission of modifier 90 claims. Update billing system edits to block modifier 90 on professional and outpatient facility claims (with exception for pathology provider claims). Train providers and billing staff that performing providers must bill laboratory services directly without modifier 90. Verify that modifier 91 claims for repeat clinical diagnostic laboratory tests continue to be submitted correctly. Audit claims submitted after December 1, 2026 to ensure compliance. Failure to comply will result in claim denials and potential overpayment recovery.