For Providers

Reimbursement Policies & Guidelines

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Effective Date: January 4, 2018

Purpose:
This policy provides guidelines for the application of modifier 54 when appropriately billed by professional providers.

Scope:
This policy applies to the Horizon NJ Health product.

Definition:
Modifier 54 is used for surgical care only when a qualified health care professional performs the surgical procedure and another provides the preoperative and/or postoperative care.

Policy:
Horizon NJ Health will reimburse surgical care services appropriately appended with modifier 54 at 75% of the applicable Horizon NJ Health fee schedule amount.

Procedure:
Modifier 54, allow at 75% of the applicable Horizon fee schedule. The above percentage is based on the numerical average of CMS.

No additional reimbursement will be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
  • Mandated or legislative required criteria will always supersede