MedicaidReimbursementHigh impact
[New York] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·NY · Pathology·Claims & Billing
Effective date
Dec 1, 2026
We identified it
Sep 2, 2026
Summary
Effective December 1, 2026, Anthem Medicaid in New York is implementing a new combined reimbursement policy for laboratory service modifiers 90 and 91. Modifier 90 (pass-through laboratory billing) is now NON-REIMBURSABLE for professional and outpatient facility claims—only the performing provider/facility can bill directly at 100% of fee schedule. Modifier 91 (repeat clinical diagnostic laboratory tests) remains reimbursable at 100% on professional claims. The existing modifier 91 policy (G-06020) will be retired and consolidated into the new policy (G-20001).
Action Required
By November 30, 2026: (1) Billing team must update billing system software to REJECT or FLAG all claims billed with modifier 90 for professional and outpatient facility laboratory services (exclude pathology provider claims from this rule). (2) Remove modifier 90 from any standing billing templates or protocols for laboratory pass-through billing. (3) Educate all billing and provider staff that modifier 90 claims will be DENIED—performing providers/facilities must bill directly instead. (4) Update internal documentation to reference new policy G-20001 instead of retired policy G-06020 for modifier 91 guidance. (5) Communicate to contracted providers and outpatient facilities that pass-through laboratory billing is prohibited; they must bill laboratory services directly. (6) Ensure compliance team confirms NO balance billing to members based on this policy change. (7) Update claim denial response templates to cite policy G-20001 for rejected modifier 90 claims. Failure to implement will result in claim denials and revenue loss for pass-through laboratory billing attempts.