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

In a previous edition of The Record, we announced that effective Sept.1, 2014, Blue Cross Blue Shield of Michigan will reject all professional, non-Medicare claims that are billed with the modifiers GY or GZ, along with modifier GA.

As part of this new policy, health care providers must present a written notice to Blue Cross members before providing medical services or supplies that are expected to be rejected. The Advance Notice of Member Responsibility form serves as this written notice, and it requires signatures from the provider and member to ensure that the member is informed and accepts financial responsibility.

Members must sign the Advance Notice of Member Responsibility form

• The provider has verified that the member does not meet the specific criteria for the service.
• The member agrees to accept financial responsibility for the service.
• The modifiers GY or GZ, along with GA, must be appended to the claim.

It’s unnecessary to use the form if:

• Providers have verified that the service is not a contract benefit. (Noncovered group benefits should follow the standard claim submission process for a rejection.)
• The member does not agree to accept financial responsibility.

 In order for the member to be financially responsible for the service:

• The provider must verify that the service does not meet the member’s benefit requirements.

• The provider must notify the member before rendering the service that the member does not meet the medical necessity requirements for the service. The provider must also explain why the member doesn’t meet the requirements. 

• The member must agree to accept financial responsibility by signing the Advance Notice of Member Responsibility form. 

Charging for “access fees” or “special access fees” is never allowed under our Blue Cross Blue Shield of Michigan provider agreements. The member can only be billed in the instances described on the Advance Notice of Member Responsibility form and if none of the services in question are benefits for which the member is eligible. Providers must seek payment from BCBSM for all covered services and must accept our fee schedule maximums as payment in full.

The form should be kept in the member’s file and available upon audit request. A copy should be provided to the member.

Keep in mind that the Advance Notice of Member Responsibility form doesn’t apply to Medicare primary claims, Medicare Advantage or MESSA group members.