For Providers

Reimbursement Policies & Guidelines

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Effective Date: January 4, 2018

Purpose:
To provide guidelines for the application of modifier 56 when appropriately billed by professional providers.

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

Definition:
Modifier 56 is used for preoperative management only when a qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure.

Policy:
Horizon NJ Health will reimburse preoperative management services appropriately appended with modifier 56 at 10 percent of the applicable Horizon NJ Health fee schedule amount.

Procedure:
Modifier 56, allow at 10 percent of the applicable Horizon NJ Health fee schedule. The above percentage is based on the numerical average of 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