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Billing Reminder – Appropriate Use of Modifier 26 for Meridian and YouthCare Plans Laboratory Services

Date: 03/30/26

Meridian and YouthCare are reminding laboratory providers of the correct use of modifier 26 (Professional Component), when submitting claims for laboratory services for Illinois Medicaid members.

Per the Illinois Department of Healthcare and Family Services (HFS) Practitioner Fee Schedule, many laboratory services are reimbursed as global services, meaning the published rate includes both the technical component, and the professional component. In these instances, modifier 26 is not separately payable and should not be appended to the procedure code.

Recent claim reviews have identified that modifier 26 has been billed for laboratory services that do not support separate professional component reimbursement under the HFS Practitioner Fee Schedule. As a result, these claims may be denied or adjusted per Illinois Medicaid reimbursement policy.

Key Billing Reminders

  • Modifier 26 should only be reported when the professional component is separately reimbursable and explicitly allowed under the applicable HFS fee schedule
  • For laboratory services identified as global on the HFS Practitioner Fee Schedule, billing with modifier 26 is not appropriate
  • Claims billed with modifier 26 when not supported by the HFS fee schedule may be subject to denial, adjustment, or recoupment

Providers must ensure that claims are submitted following:

  • The HFS Practitioner Fee Schedule
  • Applicable Illinois Medicaid billing guidelines
  • Industry standard coding requirements

We strongly encourage providers to review the HFS Practitioner Fee Schedule and related billing guidance before claim submission to ensure correct coding and to avoid claim payment delays.

If you believe a claim was billed correctly or have questions regarding appropriate modifier usage, please submit a claim dispute with supporting documentation per the Meridian Provider Manual or the YouthCare Provider Manual. Thank you for your continued partnership and compliance with Illinois Medicaid billing requirements.