HealthCare News

Pricing Claims for Medicare Statutorily Excluded Services

Issue: #399 JAN2018

Topic: Coding/Billing

The following Medicare crossover services are in place for all Blue Plans to more accurately price and process these claims:

  • For services statutorily excluded by Medicare only (e.g., home infusion therapy and hearing aids), providers should submit claims with a GY modifier on each line for the service that is excluded or not covered by Medicare to Blue Cross Blue Shield of North Dakota (BCBSND). The GY modifier is used to indicate that the item or service is statutorily excluded.This allows BCBSND to apply the provider contracted rate to accurately process the claim according to the member’s benefits. Also, by submitting statutorily excluded services with a GY modifier directly to BCBSND, payment for these services will be timelier.
  • When a provider submits a claim to Medicare for services statutorily excluded and not covered by Medicare, but the member has benefits for those services, providers will receive notification from the Blue Plan with instructions to submit those statutorily excluded services directly to BCBSND. Instructions will be included in either a paper or electronic remittance advice or in a letter from the Blue Plan.
    • Paper remittance advices and letters: When receiving paper remittance advices or letters, providers will receive instructions similar to this message: “This service is excluded or not covered under Medicare. However, the service may be eligible for benefits under other coverage. Please submit this service to your local Plan.”
    • Electronic remittance advices (835): The following HIPAA claim adjustment reason codes and remark codes will be included in the 835 responses:
      • Claim adjustment reason code (CARC) 109: “Claim not covered by this payor/contractor.”
      • Remittance advice remark code (RARC) N837: “Alert: Submit this claim to the patient’s
        other insurer for potential payment of supplemental benefits. We did not forward the claim information.”
      • Group code: OA

Frequently Asked Questions

Where on the claim do I put the GY modifier?

The GY modifier should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe services, a “not otherwise classified code” (NOC) must be used with the GY modifier.

The GY modifier is located in the line level procedure code modifier field(s), and the modifier can be:

  • Present position 1, 2, 3 or 4.
  • On the paper 1500 form, the GY modifier can be found in field 24D.
  • On the paper UB04 form, the GY modifier can be found in field 44.
  • On the 837P, the GY modifier is found at level 2400, Service Line Loop in SV101-3, SV101-4, SV101-5 or SV101-6.
  • On the 837I, the GY modifier is found at level 2400, Service Line Loop in SV202-3, SV202-4, SV202-5 or SV202-6.

Who do I contact if I have questions?

Please call BCBSND’s Provider Service at 800-368-2312 or 701-282-1090.