Member-Demanded Services and Modifiers GA, GY, GZ
Issue: #408 MAY2019
As a reminder, Blue Cross Blue Shield of North Dakota (BCBSND) will recognize and process claims with modifiers GA, GY and GZ when used as indicated below.
- GA – Member has requested a non-covered service and has signed an Advance Member Notice (AMN, also known as a “waiver”), agreeing to pay for the service. The requested service is not medically necessary for their condition. Charges will be denied, as member liable.
- GY – Benefit exclusion (including clinical ecology or cosmetic surgery). The member has been informed the service is a benefit exclusion. Certain CPT®/HCPCS codes used for excluded services can also identify covered procedures. Use of the GY modifier indicates the service should not be covered. Charges will be denied, as member liable.
- GZ – After the service is performed, it is determined to be non-covered. Member did not sign an AMN for the non-covered service. Charges are denied, as provider liable.
Services submitted using these modifiers will be denied. Medical information will not be requested or reviewed prior to the denial. BCBSND will conduct routine audits of services billed with these modifiers, requesting chart notes (and signed AMNs, if applicable) to verify appropriate usage. Services billed inappropriately will be reprocessed as provider liable. Further actions may be taken if inappropriate usage continues.
The AMN acknowledges the member is fully responsible for all charges associated with a procedure/item/service requested because the procedure/item/service may not be medically necessary and/or is not a covered benefit.
BCBSND’s AMN form is available at www.bcbsnd.com/web/providers/forms. Do not use Medicare’s form or other provider-designed waiver forms. AMNs must be completed, verbally reviewed with the member or their representative, and signed by the member before the service is provided. A copy of the signed AMN should be given to the member and the original kept on file. The signed AMN is subject to audit by BCBSND.
The AMN must specifically identify the non-covered services and procedure codes. General notices will not be accepted.
With the exception of benefit reasons, AMNs cannot be used to collect amounts otherwise not payable, including:
- Medical policy
- Providers on Corrective Action Plans
- Services provided outside the scope of the
- High charges for covered services
- Bundled services
- Items included in a procedure (i.e., surgical trays)
- Multiple procedure discounts
- AMNs cannot be used to collect from members for failure to obtain preauthorization’s or prior approvals.
- AMNs cannot be required as a condition of providing covered services.
This does not apply to the Federal Employee Program (FEP).