Clarification: Here are guidelines for using Advance Notice of Member Responsibility form

We received some questions about the Advance Notice of Member Responsibility policy since writing about it in the September Record. We’d like to provide clarity on the intended use of the Advance Notice of Member Responsibility form and the requirement for using modifiers GY or GZ and GA.

Modifiers GY or GZ are not required for every claim. If you bill for professional services using the GY or GZ modifier, Blue Cross Blue Shield of Michigan requires providers to complete the Advance Notice of Member Responsibility form. The form was recently updated and you can access it through web-DENIS or by clicking here. Once the form is complete, providers are then required to report the GA modifier. Modifier GA acknowledges that the member has signed the form prior to any services rendered and has agreed to accept financial responsibility for the service.

The form and the modifiers work together in this new policy. If the modifiers GY or GZ are not billed, the form is not required. The provider must keep the form in the member's file and provide a copy to the member.

The Advance Notice of Member Responsibility form should not be used and the modifiers should not be reported when it has been verified that a service is not a contract benefit. Providers should follow the normal billing guidelines for a routine system rejection for noncovered group benefits. In addition, the form should not be used and the modifiers should not be reported if the member does not agree to accept financial responsibility. The Advance Notice of Member Responsibility policy does not apply to facility services, MESSA group members, Medicare primary or Medicare Advantage members. It also does not apply in the following scenarios:

• The health care practitioner provides professional services that are not a contract benefit. (The system already has edits to reject as not a benefit.)
• The member refuses to sign the form.
• The provider did not verify coverage.

The Advance Notice of Member Responsibility form is only required when the modifiers GY or GZ and GA are reported for the service. All services reported with modifiers GY or GZ must be reported with a modifier GA in order for the claim to reject as the member responsibility. If the provider reports the GY or GZ modifier alone, the service will be rejected as the provider’s responsibility.