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CPT Modifier GA, GX, GY or GZ


Provider Administrative Policy

Section
Claims Submission
Policy Date
November 2007
Status/Date
Revised/October 2011
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

CPT Modifier GA, GX, GY or GZ

The GA modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect Blue Cross of Idaho will deny a service as not reasonable and necessary and they do have an Advanced Beneficiary Notice (ABN) signed by the member.

The GX modifier should be used when physicians, practitioners, or suppliers want to indicate that they issued a voluntary ABN. Providers can bill the GX modifier on the same claim line as the GY modifier.

The GY modifier should be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare-covered benefit.

The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Blue Cross of Idaho will deny an item or service as not reasonable and necessary and they have not had an advance beneficiary notification (ABN) signed by the member.

Effective process date 05/16/2011, claims submitted with GA, GX or GY modifiers indicating a valid ABN has been signed, will process as member liability.

Prior to process date 05/16/2011, Blue Cross of Idaho will initially process claims for items and services billed with a GA, GX, GY or GZ modifier by a contracted provider as a contractual adjustment to the provider. When the provider wishes to bill the member for those items or services, he or she must take the following steps.

  1. Contact the Blue Cross of Idaho Customer Service Department and identify that a member signed a valid ABN for the services in question.
  2. Fax or mail a copy of the ABN to Blue Cross of Idaho so we can verify that it is a valid ABN.

Upon verification of a valid ABN, Blue Cross of Idaho may re-adjudicate the claim to reflect member liability. The provider will receive a new remittance advice indicating member liability and the member will receive an explanation of benefits informing them of their financial obligation. The provider may then bill the member for the item or services in question.

Please keep in mind:

  • Providers may not use the ABN to circumvent Blue Cross of Idaho prior authorization requirements.
  • Providers should use ABN forms available on the CMS website, the generic ABN attached to this policy, or any other ABN form that contains all of the required elements for a valid ABN.
  • Blue Cross of Idaho recommends giving a copy of the signed ABN to your patients for their records.
  • Format ABNs in 12-point font and include the following information: 
    • member name 
    • date of service
    • specific service in question (i.e., MRI lumbar spine)
    • reason why item or service may not be covered 
    • cost of item or service 
    • member signature 
    • date ABN signed by member.

ABN example attachment


Policy History

Date Action Reason
October 2011 Revised Removed GZ modifier for claims processed 05/16/2011
September 2011 Revised Added member liability information
November 2010 Revised GX Modifier added
May 2008 Revised Title change

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