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Geisinger becomes the first member of Risant Health

GHP Family uses a case rate methodology for services billed with the SG modifier in the outpatient setting. An SG modifier should be billed only on services deemed eligible for the modifier in accordance with the Pennsylvania Department of Human Services (DHS) Medicaid Fee Schedule.

Refer to the DHS Medicaid Fee Schedule available at

Only the SG-eligible service with the highest allowed case rate is reimbursed for GHP Family claims having more than one SG-eligible service billed on the same date of service. The highest SG modifier case rate will only be paid if the SG modifier is present on the claim. Be sure to bill all services with the appropriate modifiers, as specified in the current DHS Medicaid Fee Schedule, to ensure timely and accurate reimbursement.

Claims with dates of service on or after Thursday, Aug. 1, that do not bill correctly for multiple SG eligible services on your GHP Family claims will result in denials and may involve the recoupment of Medical Assistance payments made in error. Edits in place to review SG modifier use are line item driven. This means the surgery line on your claim will deny while other claim lines may continue to pay.

Consider the following guidance from DHS when billing SG-eligible services for your GHP Family patients:

  • Bill all SG-eligible services performed during the same encounter on a single claim submission for outpatient surgical procedures.
  • List the procedure with the highest allowed case rate on the first claim line, the procedure with the next highest fee on the second claim line and so on.


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