GY and GZ modifiers, Advance Notice of Member Responsibility required for all claims that BCBSM is expected to reject

Beginning Sept. 1, 2014, all professional, non-Medicare claims that include the modifiers GY or GZ, along with modifier GA, will be rejected. The member will be responsible for paying for the services provided.  

Blue Cross Blue Shield of Michigan is adopting Medicare’s Advance Beneficiary Notice policy and refers to it as Advance Notice of Member Responsibility. Health care providers should include the GA modifier on all claims billed with a GY or GZ modifier, which will acknowledge that:

• The services are expected to be rejected.
• The member was informed and agreed to accept total responsibility.
• An Advance Notice of Member Responsibility form was signed prior to services rendered and is on file.
• This does not apply to Medicare supplemental and MESSA group member claims.

If providers don’t include the GA modifier on claims appended with a GY or GZ modifier, they will be held responsible for the cost of the services. 

Advance Notice of Member Responsibility
Providers must present a written notice to Blue Cross members before providing medical services or supplies that are expected to be rejected.

For the notice to be acceptable, a provider must:

• Use Blue Cross’ Advance Notice of Member Responsibility form for dates of services on or after Sept. 1, 2014.
• Complete the responsibility form in its entirety.
• Clearly identify the particular item or service that is expected to be denied.
• State the specific reason that BCBSM will deny payment for the particular item or service.
• Indicate the estimated cost of the item or service that is associated with the denied claim and the member is responsible.

Member responsibility form
The form should be issued prior to rendering a service or dispensing durable medical equipment, prosthetics and orthotics, or medical supplies that Blue Cross isn’t expected to cover. This form does not take the place of or change any member’s benefits.

Here are some reasons why the medical claims for those items may be rejected:

• Blue Cross medical criteria have not been met.
• Blue Cross doesn’t usually pay for this many treatments or services.
• Blue Cross doesn’t usually pay for this service.
• Blue Cross doesn’t pay for this service because it’s a treatment that hasn’t been proven safe or effective.
• Blue Cross doesn’t pay for this many services within this period of time.
• Blue Cross doesn’t pay for such an extensive treatment.
• Blue Cross doesn’t pay for this medical equipment for the illness or condition stated.

If a provider properly issues a notice, the member will be held financially liable for the reason indicated on the signed form. Keep in mind that a provider who fails to properly issue a notice will be held liable for the medical service. The provider will not be allowed to bill or collect funds from the member, and the provider must refund money collected from the member.

Other important information about the Advance Member Notice of Responsibility form

• For an extended course of treatment, a member responsibility form is valid for one year. If the course of treatment extends beyond one year, a new form is required each year for the remainder of the treatment.

• Once signed by the member, a member responsibility form may not be modified or revised. When a member must be notified of new information, a new form must be provided and signed.