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New Required Modifier for Habilitative and Rehabilitative Services

Date: 03/25/19

Habilitative and rehabilitative benefits are considered Essential Health Benefits (EHBs) under the Affordable Care Act (ACA). Habilitative services help a person learn, keep, or improve skills and functioning for daily living.

While rehabilitative services are necessary after an illness or injury to help a person restore, keep, or improve skills and functioning for daily living. Many times, the same CPT code can be used for both types of services. On January 1, 2018, new modifiers were introduced to help distinguish between these two benefits. Ambetter is requiring modifier ‘96’ is to be used for any habilitative service or procedure that could be considered either habilitative or rehabilitative. Rehabilitative services should continue to use modifier 'GN' for speech therapy, 'GO' for occupational therapy, and/or 'GP' for physical therapy.

The new modifiers will be required starting July 1, 2019 but our systems can accept them now. If you have questions about this or any other billing matters, please reach out to Provider Services at 1-877-687-1196.