Medicare AdvantageReimbursementHigh impact
[New York] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·CT, GA, IN, KY, MO, NV, NY, NH, OH, WI · Pathology·Claims & Billing
Effective date
Dec 1, 2026
We identified it
Sep 2, 2026
Summary
Anthem Medicare Advantage is implementing a new reimbursement policy effective December 1, 2026, that prohibits pass-through laboratory billing (modifier 90) for professional and outpatient facility providers, requiring them to bill directly instead. The existing modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and has been consolidated into this new combined policy.
Action Required
By November 30, 2026: Billing team must audit all laboratory billing processes to eliminate use of modifier 90 on professional and outpatient facility claims submitted to Anthem Medicare Advantage. Update billing software to block or flag modifier 90 submissions for these claim types. Ensure all laboratory services are billed directly by the performing provider or facility rather than through pass-through billing arrangements. Confirm modifier 91 claims for repeat laboratory tests continue to be submitted at 100% of applicable fee schedule or contracted rate. Providers must be informed that balance billing members based on this policy change is prohibited. Failure to comply will result in claim denials for any modifier 90 billed claims on or after December 1, 2026. Exception: Pathology providers' use of modifier 90 is unaffected by this policy.