For Providers

Reimbursement Policies & Guidelines

Text Size

Effective Date: January 4, 2018

Purpose:
This policy provides guidelines for the reimbursement of eligible services appropriately appended with Modifier 55 by professional providers.

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

Definition:
Modifier 55 is used for postoperative management only when a qualified healthcare professional provides postoperative care and another performed the surgical procedure.

Policy:
Horizon NJ Health will reimburse post-operative management services appropriately appended with Modifier 55 at 15 percent of the applicable Horizon NJ Health fee schedule amount.

Procedure:
Modifier 55, allow at 15 percent of the applicable Horizon NJ Health fee schedule. This percentage is based on the numerical average of the Centers for Medicare and Medicaid Services (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