Modifier SU reimbursement policy

Horizon Blue Cross and Blue Shield of New Jersey
Reimbursement Policy
Title: Modifier SU
Effective Date: May 26, 2014
Last Revised Date:
Purpose:
This policy provides guidelines for services appended with modifier SU for participating and
nonparticipating providers.
Scope:
All products are included, except for products where Horizon BCBSNJ is secondary to Medicare
(e.g. Medigap). This initiative is applicable to both insured and ASO accounts for all products with the
exception of the below:
 Professional claims with a date of service prior to 05/19/2014
 SHBP claims prior to implementation date
 Professional claims outside the office
 Claims that do not contain Modifier SU
 Facility claims
 Par other
 ITS Home Par
 ITS Host Medicare Advantage Non PPO
 ITS Host Medicare Advantage Non Par
 ITS Host Medigap
 ITS Host Medicaid
 Labor Accounts (OON providers MPL and Flexlink)
Policy:
Services appended with modifier SU will not be separately reimbursed and will deny as ineligible for
separate reimbursement. Modifier SU is used to denote the use of the facility and equipment for a
procedure performed in a physician’s office. The use of the office facility and equipment is included in
the practice expense Relative Value Units (RVU) or the cost associated with operating the office.
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.
Procedure:
Reject all service lines on a professional claim that are appended with modifier SU.
For participating providers the member should not be billed for this service as the member is not liable for
services billed with modifier SU.
If billed by a nonparticipating provider the member can be billed for the charges when submitted with
modifier SU.
Policy 073 Modifier SU FINAL 4-22-14 ONLINE.doc
04/22/2014
Final Version 1.0
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