CurrentAnthemPolicy N/A

Statutorily Non-Covered Services (Medicare Advantage)

Defines statutorily excluded services for Medicare and explains when and how Medicare Advantage members or contracted providers may obtain coverage, notifications, and billing modifiers; applies to contracted providers serving Anthem Medicare Advantage members.

Policy Summary

PayerAnthem

PolicyStatutorily Non-Covered Services (Medicare Advantage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf a service is statutorily excluded, contracted providers must request a Notice of Denial of Medical Coverage (NDMC) from the plan prior to rendering the service and submit claims with the appropriate G modifier(s) attaching the NDMC when issued.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3G-modifiers referenced

6+Example exclusions listed

RequiredNDMC required

ProhibitedABN permitted for MA

Coverage Stance and Requirements

Policy Summary

PayerAnthem

PolicyStatutorily Non-Covered Services (Medicare Advantage)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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ALL of the following

Follow the supplemental benefit vendor and network rules per the member's EOC and Provider Contract (e.g., routine vision, hearing, dental may be provided via supplemental benefit vendor).

ALL of the following

The contracted provider should contact the Medicare Advantage plan Provider Service Department to request a Notice of Denial of Medical Coverage (NDMC) prior to rendering the service. Providers are considered agents of the MA plan and are held responsible for ensuring CMS notification requirements are met.
If an NDMC is issued prior to the service, submit the claim with the appropriate G modifier(s) per Anthem configuration (GX and/or GY as applicable) and attach the NDMC; file claims for services rendered even if NDMC was issued to allow appeals.
If the NDMC is not issued prior to the service, the claim may be denied and the provider may be held financially responsible; do not use an Advanced Beneficiary Notice (ABN) for Medicare Advantage members.

ALL of the following

Contact the Medicare Advantage plan Provider Service Department to request an NDMC/coverage determination before providing the service. Providers must supply member and claim details when requesting the NDMC.

ALL of the following

Submit claims with Anthem-configured modifiers: GX for statutorily non-covered services; GY when the item/service is statutorily non-covered and proper notification has been secured (NDMC issued). Attach the NDMC to the claim. Claims should be submitted for all services rendered to permit appeals if needed.

Modifier and Billing Codes

Anthem G-modifier guidance for statutorily excluded servicesModifier

GX	Statutorily non-covered service; use for statutorily excluded services. The contracted provider is to submit the claim with a GX modifier.
GY	Statutorily non-covered or not a Medicare benefit and proper notification has been secured; use for statutorily excluded services when a Notice of Non-Coverage has been issued. The contracted provider is to submit the claim with a GY modifier.
GZ	Indicates expected Medicare denial as not reasonable and necessary without advanced notice; not appropriate on statutorily excluded services.
GA	Indicates expectation Medicare will deny; use is not appropriate on statutorily excluded services.

Provider Steps, Notifications, and Claim Submission

Note

Request NDMC before service and submit claim with G‑modifier and NDMC attached

If a service is statutorily excluded, contracted providers must request a Notice of Denial of Medical Coverage (NDMC) from the Medicare Advantage plan prior to rendering the service; the NDMC must be issued by the plan and will be mailed to the member and faxed to the provider. Submit the claim with the appropriate G modifier(s) (per Anthem configuration) and attach the NDMC when issued; claims without the required NDMC and modifier will be denied and the provider held financially responsible. When requesting the NDMC from Provider Services, supply member and claim details (Member ID, date of service, member name/DOB, servicing provider/TIN, facility/address/TIN, ordering physician/address/TIN, provider fax number, diagnosis, and CPT code(s)).

Request the NDMC from the plan’s Provider Service Department before the service is provided; the plan issues the letter (cannot be provided by provider).
File the claim with the appropriate Anthem G modifier (GX/GY as configured) and submit the NDMC with the claim; claims should be submitted for all services rendered so appeals may proceed.
Provide required member and claim information when requesting the NDMC: Member ID (with prefix), date of service, member name/DOB, servicing provider/TIN, servicing facility/address/TIN, ordering physician/address/TIN, provider fax number, diagnosis, and CPT code(s).

Key Definitions and Examples

Statutorily non-covered service

DefinitionServices excluded from Medicare coverage by statute (examples): eye refractions with the Medicare covered vision exam; custodial care; hearing aids; routine dental services; routine vision services; services not provided within the United States.

Implication for providersStatutorily excluded services are not Medicare-covered benefits; check the member's MA plan EOC to determine whether the plan offers the service as a supplemental benefit.

Member optionsIf the MA plan offers the service as a supplemental benefit, follow the plan's supplemental benefit rules and vendor/network requirements per the member's Evidence of Coverage.

Notice of Denial of Medical Coverage (NDMC)

DefinitionNotice of Denial of Medical Coverage (NDMC): a plan-issued letter that notifies the member the service is not covered, explains member financial liability and appeal rights, and must be issued by the MA plan prior to the service.

Provider action to obtainContracted providers should contact the plan's Provider Service Department to request an NDMC; the plan issues the letter to the member and provides a copy to the provider (e.g., via fax).

Billing impactWhen NDMC is issued prior to service, submit the claim with the appropriate G modifier(s) and attach the NDMC; claims without required notification may be denied and the provider held financially responsible.

Advanced Beneficiary Notice (ABN)

DefinitionAdvanced Beneficiary Notice (ABN): a notice used in Medicare Fee‑For‑Service only; CMS prohibits use of ABNs for Medicare Advantage members.

Alternate for MAMA plans and their contracted providers must use the plan‑issued Notice of Denial of Medical Coverage letter (pre‑determination denial) rather than an ABN.

ScopeThe ABN fulfills notice functions only for beneficiaries in Medicare FFS and is not applicable to services or Part D drugs provided under the Medicare Advantage program.