Blue Cross implements Member Upgrade Responsibility Policy for DME and P&O

Blue Cross Blue Shield of Michigan implemented a new policy known as the Member Upgrade Responsibility Policy, effective May 1, 2015.

The policy is a written notice that allows durable medical equipment and prosthetics and orthotics providers to bill the member for the difference of a medically necessary item and an upgraded item. Providers will receive reimbursement from Blue Cross for the medically necessary item and bill the member for the difference of prevailing fees for the upgrade item received.

An upgrade is an item with features that goes beyond what is medically necessary. This item can either be more expensive, contain more components or features, or is greater in quantity than what is medically necessary. Blue Cross members will be responsible for paying the difference of the prevailing fees or the retail cost for the medically necessary item and the upgrade item. Providers will present the Member Upgrade Responsibility form to the member before providing the item or service.

The Member Upgrade Responsibility form can be used for all Blue Cross Blue Shield of Michigan members, except for MESSA, Medicare primary and Medicare Advantage members. This policy does not apply to Not Otherwise Classified or to Individual Consideration HCPCS codes. Providers cannot substitute one item for a totally different item (for example, you cannot substitute a wheelchair when the member was prescribed a walker or you cannot substitute a hospital bed when a wheelchair was prescribed).

The provider must bill both items on the same claim form in sequential order with the GA modifier on the first line for the upgrade item and the GK modifier on the second line for the medically necessary item, along with any other applicable modifiers to identify rental or purchase. Rental DME items that have been upgraded should include the upgrade modifiers on the monthly claims (10 months for capped rental). The Member Upgrade Responsibility form should reflect the difference the member is responsible for paying. Only the two claim lines are required on the claim form when billing for an upgrade item; no other procedure codes should be billed on the same claim form.

These modifiers when billed collectively will acknowledge the following:

• The member was informed and agreed to accept total responsibility of the difference between the medically necessary item and the upgraded item
• A Member Upgrade Responsibility form was signed prior to services rendered and is on file
• This policy does not apply to Medicare primary and Medicare Advantage members

Line 1: Modifier GA for upgraded item
Bill the appropriate HCPCS code for the upgraded item that the supplier actually provided to the member with the charge amount and the Blue Cross fee for the upgrade

Line 2: Modifier GK for medically necessary prescribed item
Bill the appropriate HCPCS code for the reasonable and necessary item with the charge amount and the Blue Cross fee for the medically necessary item.

For the Member Upgrade Responsibility form to be acceptable, the provider must:

• Use the designated Blue Cross Member Upgrade Responsibility form (starting with dates of service on or after May 1, 2015).
• Complete the Blue Cross Member Upgrade Responsibility form in its entirety
• Provide a detailed description of the upgrade item received
• Indicate the cost difference between the medically necessary item and the member upgrade item

Modifier GA, when billed alone, has no impact on claims processing, however, if billed on the same claim with a modifier GK, it represents a non-medically necessary upgrade item and will be rejected. The member will be liable.

The purpose of modifier GA is to acknowledge the patient has a signed Member Upgrade Responsibility form on file and accepts liability for the rejected service line for the non-medically necessary upgrade item.

The purpose of modifier GK is to identify the medically necessary item ordered by the physician. Modifier GK, when billed alone, has no impact on claims processing.

Free upgrade: Report modifier GL
When providing a free upgrade, providers should submit the claim with the appropriate HCPCS code for the non-upgraded item or service that the physician ordered. Providers should report modifier GL only with the correct, non-upgraded HCPCS code. The provider should specify the make and model of the upgraded item or service that was provided in Item 19 of the CMS-1500 claim form or as an attachment to the claim.

When providing a free upgrade, the supplier should not have the member sign a Member Upgrade Responsibility Form, because the supplier should not be charging the member more than the normal deductible and co-payment for the non-upgraded item. The upgraded item should not be billed.

Claim form example for free upgrade:
Claim Line 1 HCPCS Code XXXXX Modifier GL...Pay (Free Upgrade Modifier GL is billed alone)

The Member Upgrade Responsibility form can be found on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Search the Frequently Used Forms column.