CurrentBlue Cross Blue Shield - NevadaPolicy G-10002

Sanctioned and Opt-Out Providers

Defines reimbursement stance and claim handling for providers who are excluded/debarred or who have opted out of Medicare for members of Anthem Blue Cross and Blue Shield plans in listed states, including requirements for urgent/emergent care billing.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicySanctioned and Opt-Out Providers

Policy CodePolicy G-10002

Change TypeNo material changes (clarified)

Effective Date12/30/2024

Next Review Date

Key ActionInclude Modifier GJ on claims for emergency or urgent care when rendered by an opt-out Medicare provider.

SourceLink

POLICY UPDATE CHANGES

Removed 'Reimbursement of' from title and updated policy template.

12/30/2024 review approved and effective with no changes.

G-10002Policy number

12/30/2024Effective

Multiple statesGeographies

1Coding note

Sanctioned and Opt-Out Provider Coverage

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Sanctioned and Opt-Out Provider Criteria

Coverage stance and decision logic for reimbursement of services provided by sanctioned/excluded or Medicare opt-out providers.

ALL of the following

Provider status
- Provider is NOT excluded or debarred from participation in state or federal healthcare programs (if provider is excluded or debarred, claims will be denied).
- If the provider has opted out of Medicare, the service is limited to urgent or emergent situations for which reimbursement is allowed.
Claims must be billed with proper CPT, HCPCS and/or revenue codes and fully supported in the medical record or office notes.
The health plan screens providers through applicable state and federal exclusion lists.

ALL of the following

Claims submitted by providers excluded or debarred from state or federal healthcare programs will be denied (no reimbursement), unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

ALL of the following

Reimbursement to providers who have opted out of Medicare is allowed only for urgent or emergent situations.
When an opt-out provider renders urgent or emergency care, Modifier GJ is required on the claim.
Payment may not be made for services furnished by an opt-out physician or practitioner who has signed a private contract with a Medicare beneficiary for emergency or urgent care items.

ALL of the following

Services should be billed with CPT, HCPCS and/or revenue codes and must be fully supported in the medical record and/or office notes.

Modifiers, Codes and Coding Standards

Modifiers and coding guidanceModifierCovered

GJ	Modifier required on claims for emergency or urgent care services when rendered by an opt-out provider

Coding standards — billing requirements

Required billing codesServices must be billed with CPT, HCPCS and/or revenue codes and these codes must be fully supported in the medical record and/or office notes.

Support in medical recordWhen billed, codes must be fully supported in the medical record and/or office notes.

Industry standard complianceEnsure use of proper billing and submission guidelines, including industry‑standard, compliant codes on all claim submissions.

ApplicabilityUnless otherwise noted, reimbursement policies apply to both participating and non‑participating professional providers and facilities.

Claim Handling, Denials, and Urgent/Emergent Reimbursement Rules

Denial Risk

Claim Denial and Urgent/Emergent Reimbursement Rules

The health plan will deny claims and withhold reimbursement for services submitted by providers who are excluded or debarred from participation in state or federal healthcare programs, or who have otherwise been sanctioned. Providers must not bill the plan if they appear on applicable state or federal exclusion lists; the plan screens providers against these lists and will deny claims for excluded providers. Do not submit claims for excluded or debarred providers.

Providers excluded or debarred from state or federal healthcare programs — claims denied
Providers who have opted out of Medicare — generally not reimbursed except for urgent/emergent care
Modifier GJ required on claims for emergency or urgent care services rendered by a Medicare opt‑out provider
The plan screens providers against all applicable state and federal exclusion lists

Key Definitions

Opt‑out provider — explanation

DefinitionA provider who has formally opted out of participation in Medicare under applicable rules; such providers have elected not to participate in the Medicare program and may enter into private contracts with beneficiaries.

Reimbursement stanceClaims submitted by an opt‑out provider will be denied unless state, federal, or CMS contracts indicate otherwise; reimbursement to opt‑out providers is allowed only for urgent or emergent situations.

Modifier requirementWhen an opt‑out provider renders urgent or emergency care, Modifier GJ is required on the claim.

Private contract notePayment may not be made for services furnished by an opt‑out physician or practitioner who has signed a private contract with a Medicare beneficiary for emergency or urgent care items.

Sanctioned or excluded provider — explanation

DefinitionA provider who is excluded or debarred from participation in state or federal healthcare programs (sanctioned/excluded provider).

Reimbursement stanceThe health plan does not allow reimbursement for services submitted by providers excluded or debarred from participation in state and federal healthcare programs; such claims will be denied unless provider, state, federal, or CMS contracts indicate otherwise.

ScreeningThe health plan screens providers through all applicable state and federal exclusion lists.

Policy Changes and Review History

2024-12-30review_approvedLatest

Review approved and policy effective with no substantive changes.

2022-12-27edit

Title wording updated by removing 'Reimbursement of' and policy template updated (housekeeping).

2020-11-06review_approved

Review approved with no policy language changes noted.

2018-10-03template_update

Policy template updated.

2016-10-03template_update

Policy template updated.

2015-11-09template_update

Policy template updated.

2015-01-01initial_approval

Initial approval and effective date of the policy.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicySanctioned and Opt-Out Providers

Policy CodePolicy G-10002

Change TypeNo material changes (clarified)

Effective Date12/30/2024

Next Review Date

Key ActionInclude Modifier GJ on claims for emergency or urgent care when rendered by an opt-out Medicare provider.

SourceLink

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