CMS allows Medicare Advantage (MA) plans to create billing and payment rules that are different from Original Medicare rules. For further information, go to Section 10.2, Chapter 4 of the Medicare Managed Care Manual.

 

For HMSA to know if contracting providers have given proper notice of non-coverage to our Medicare Advantage plan members, providers must follow our billing rules and use the modifiers as follows.

 

GA - Pre-service notice of non-coverage was provided by the plan.

Use this modifier to tell us that:

• The plan made an organization determination though Medical Management, HMSA's pharmacy benefit manager, NIA/Magellan, Landmark, etc., and gave provider and member the HMSA denial notifications before the patient received the non-covered services.
• The member either refused the provider's offer of obtaining a pre-service determination and wanted to proceed with the service; or the member does not want to appeal a denial of coverage notice from HMSA and wanted to proceed with the service.[i]

The claim will go to patient liability and you may bill the member.

If you bill us for non-covered services without using the GA modifier, HMSA will deny your claim. It will go to provider liability.

 

GZ - Service is not covered by Medicare

The GZ modifier identifies that 1) an item or service is expected to be denied as not reasonable and necessary, and 2) no advance notice of non-coverage was supplied to the member.

 

If you bill us for services using the GZ modifier, the claim will go to provider liability and you may not bill the member.

 

Unless the service is clearly excluded in a member's EOC or other related materials, providers must request a pre-service organization determination if they know or have reason to know that a service they are rendering or referring may not be covered.
 

Providers do not need to request a pre-service organization determination if the service is clearly excluded in the member's EOC or other related materials.

 

The GX modifiers are not needed for services that are considered statutorily noncovered, or that do not meet the definition of a Medicare benefit.

 

GY modifier is added to claims in which the item or service is statutorily excluded, does not meet the definition of any Medicare benefit.


Correct Use

• Append when services are provided under statutory exclusion from Medicare Program
• It is not necessary to provide patient with an ABN for these situations
• Situations excluded based on a section of the Social Security Act
• Append to cause claim to deny with patient liable for charges *

*Will only be applicable when it specifically stated in Medicare or HMSA’s MA coding guidelines the appropriateness of appending the GY mod for services not meeting the coverage criteria.

Incorrect Use

• Appending to bundled procedures
• Appending to add-on codes
• Appending to MUE codes
• Appending to services that are non-covered by Medicare but covered as a plan supplemental benefit, e.g., routine vision services
• Non-covered services where HMSA made a coverage determination prior to member getting the service. 

 

HMSA QUEST Integration

The GY modifier is recognized by QUEST Integration plans, however, providers should follow the HMSA QUEST Integration correct billing instructions for this modifier, refer to QUEST Integration - Third Party Liability - Coordination of Benefits - QUEST Integration and Medicare.

 

 

---

[i] A copy of the signed Acknowledgement of Financial Responsibility must be submitted with the service in addition to modifier GA.