CurrentAnthemPolicy N/A

Statutorily non-covered services and Notice of Denial process

Governs how Medicare Advantage contracted providers must handle services excluded from Medicare by statute, notification requirements to members, modifier/billing guidance, and liability when services are non-covered. Affects Anthem-contracted providers servicing Medicare Advantage members.

Policy Summary

PayerAnthem

PolicyStatutorily non-covered services and Notice of Denial process

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionRequest a Plan-specific Notice of Denial of Medical Coverage (NMDC) from Provider Service prior to rendering a statutorily non-covered service and include required member and claim details so the plan can issue the NMDC and permit member liability and appeals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

GA/GX/GY/GZG modifier types described

6 example excluded servicesExamples listed

Notice of Denial requiredNMDC required before liability

Provider contact info listMinimum NMDC request data

Statutorily Non-Covered Services

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Statutorily Non-Covered Services Coverage Criteria

Coverage stance and member/provider responsibilities for statutorily excluded services under Medicare Advantage:

Some services are statutorily excluded from Medicare; Medicare Advantage (MA) plans may elect to offer these as supplemental benefits per the member's Evidence of Coverage (EOC).

If the EOC or supplemental benefit applies: If the EOC or supplemental benefit covers the service, follow the supplemental benefit vendor/EOC requirements (member may need to obtain the service through the supplemental benefit vendor).

If the service is never covered per the EOC

The contracted provider should call the Provider Service Department and request the Plan-specific NMDC; the plan will issue the letter to the member and send a copy to the provider.
The NMDC advises the member the service is not covered, explains member financial liability and appeal rights, and must be issued by the MA organization (providers may not issue their own template).
If the NMDC is not provided to the MA member for a non-covered service, the claim may be denied and the provider may be held financially responsible; by CMS rules, claims from contracted providers that do not follow notification guidelines will be denied to the provider and the member cannot be held financially liable.

Billing and claims submission: Submit claims for services rendered even when an NMDC has been issued; include the NMDC with the claim and bill with the appropriate G modifiers (see coding guidance). If the member appeals a rendered service, a claim with appropriate modifiers and documentation must be on file.

Provider responsibilities: NMDC request data: When requesting an NMDC from Provider Service, provide required member and claim details (member ID, date of service, member name/DOB, servicing provider/TIN, facility info, ordering physician info, provider fax, diagnosis and CPT code(s)).

Modifier and Billing Guidance

G-modifier guidanceModifier

GX	Item or service is statutorily non-covered or is not a Medicare benefit; use for statutorily excluded services. The contracted provider is to submit the claim with a GX and GY modifier.
GY	Item or service is statutorily non-covered or is not a Medicare benefit; use when a Notice of Non-Coverage has been issued or when the EOC is clear that the item is never covered. The contracted provider is to submit the claim with a GX and GY modifier.
GA	Indicates expectation Medicare will deny; not appropriate on statutorily excluded services.
GZ	Indicates expectation Medicare will deny as not reasonable and necessary with no advanced notice; not appropriate on statutorily excluded services.

Provider Workflow for Non-Covered Services

Prior Authorization

Request Plan‑specific Notice of Denial (NMDC) before rendering statutorily non‑covered services

If a member requests a statutorily non‑covered service, the contracted provider must call the Provider Service Department to request a Plan‑specific Notice of Denial of Medical Coverage (NMDC). The NMDC will be issued to the member and a copy faxed to the provider; it must be issued prior to the service to permit member liability and to establish appeal rights. When requesting the NMDC, provide the member ID (including 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).

Call Provider Service Department and ask for a Notice of Denial of Medical Coverage letter to be issued (letter mailed to member; copy faxed to provider).
Provide required data: 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, CPT code(s).
Submit the NMDC with the claim and bill with the appropriate G modifier; if NMDC was not issued prior to service, claims from contracted providers not following CMS guidelines will be denied to the provider and the member cannot be held financially liable.

Key Definitions

Statutorily non-covered service — definition and examples

DefinitionServices excluded from Medicare coverage by statute (examples include: 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).

When may a statutorily non-covered service be offered?Medicare Advantage Plans may choose to offer some statutorily excluded services as supplemental benefits; check the member's Evidence of Coverage or Provider Contract or contact Provider Service for details.

Provider responsibilityContracted providers are considered agents of the MA plan and are responsible for ensuring CMS notification requirements are met prior to rendering statutorily non-covered services.

Member liability consequenceIf a service is never covered per the EOC and proper pre-service notice is not obtained, the member could be held liable for payment; providers should obtain a Plan-specific Notice of Denial of Medical Coverage (NMDC) to document notice.

Notice of Denial of Medical Coverage — definition and purpose of NMDC (plan-specific pre-service denial letter)

DefinitionNotice of Denial of Medical Coverage (NMDC) is a plan‑specific pre‑service denial letter issued by the Medicare Advantage organization to inform the member that a service is not covered and to establish appeal rights.

PurposeTo advise the member that the service is not covered, explain member appeal rights, and permit accurate claim processing and potential member financial liability when issued prior to service.

How to obtainContracted providers should call the Provider Service Department to request a Plan‑specific NMDC; the letter will be issued to the member with a copy faxed to the provider.

CMS/ABN noteCMS prohibits use of the ABN for MA members; the MA plan must issue the NMDC (plans may not provide an ABN template for providers to use).

Required information when requesting NMDCProvide member ID, date of service, member name/DOB, servicing provider/TIN, facility and ordering physician details, diagnosis and CPT code(s), and provider fax for delivery.