CommercialReimbursementHigh impact
[New York] New reimbursement policy: Modifiers 90, 91, and 92: Laboratory Services — Professional and Facility
Anthem BCBS·NY · Pathology·Claims & Billing
Effective date
Nov 1, 2026
We identified it
Aug 2, 2026
Summary
Anthem is implementing new reimbursement guidance for laboratory service modifiers effective November 1, 2026. Modifier 90 (pass-through laboratory billing) is now NOT reimbursable—the performing provider/facility must bill directly. Modifiers 91 and 92 retain existing guidance with no changes, but modifier 92 is limited to only 6 specific codes.
Action Required
By October 15, 2026: Billing team must implement the following changes in billing software and provider communication: (1) STOP accepting and reimbursing ANY claims billed with modifier 90—reject these claims and instruct providers that the performing laboratory/facility must bill directly at 100% of fee schedule/contracted rate; (2) Confirm modifier 91 remains eligible for reimbursement on professional claims for repeat laboratory tests at 100% of applicable fee schedule; (3) RESTRICT modifier 92 reimbursement to ONLY the six specified codes (86701, 86702, 86703, 87389, G0432, G0433) on professional claims—deny all other codes with modifier 92; (4) Update billing system validation rules to enforce these restrictions; (5) Notify all in-network providers and laboratories in New York of the changes with written guidance; (6) Train billing staff on new modifier rules and denial reasons. Failure to implement will result in incorrect claim reimbursement and potential overpayments. NOTE: Pathology services billed with modifier 90 by pathology providers are excluded from the modifier 90 non-reimbursement rule.