CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Advance Notice of Noncoverage (ANN) / ABN and HCPCS modifier use

Governance of provider use of Advance Notice of Noncoverage (ANN)/ABN and related HCPCS modifiers (GA, GU, GX, GZ) for Blue Cross Blue Shield - Rhode Island commercial products; explains when member liability may be assigned and provider responsibilities.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAdvance Notice of Noncoverage (ANN) / ABN and HCPCS modifier use

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2015

Next Review DateMay 1, 2025

Key ActionIssue a signed ANN listing the service and cost estimate, verbally review it with the member, provide a copy to the member, and retain the original before assigning member financial liability.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4HCPCS modifiers discussed (GA, GU, GX, GZ)

CommercialProduct type

Provider liable if no ANNMember liability rule

ANN requirementsDocumentation required

When Member May Be Liable

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAdvance Notice of Noncoverage (ANN) / ABN and HCPCS modifier use

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2015

Next Review DateMay 1, 2025

SourceLink

On This Page

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Member liability and modifier criteria

Rules for when a member may be held financially liable and how HCPCS modifiers interact with coverage and billing decisions:

Providers must issue an Advance Notice of Noncoverage (ANN) prior to performing a service that is believed to be not covered or not medically necessary if they intend to assign financial liability to the member.

ANN documentation must include the specific service/item believed to be not covered or not medically necessary; an estimate of the cost; verbal review with the member or representative with questions answered prior to signing; delivery far enough in advance to allow an informed decision; and a copy of the signed ANN must be given to the member while the issuer retains the original.

If an ANN is not provided for a non-covered service, the provider is financially liable for the service/item provided to the member.

If a service requires preauthorization and authorization is denied, the denial notice substitutes for an ANN if the member elects to proceed; the provider must submit the claim with the appropriate modifier(s) and the claim will deny with member liability assigned.

Use GA or GZ only when an ANN has been issued and documentation meeting the ANN requirements is retained; GU or GX may be used for care typically excluded from coverage (e.g., cosmetic surgery) to provide notice of liability and will result in claim denial with member liability assigned.

Do not append GA/GU/GX/GZ routinely or when the provider does not expect denial; inappropriate use may trigger audit and corrective action. These modifiers should not be used for Medicare Advantage Plans.

An ANN is not to be issued for services that are covered but not separately reimbursed or are bundled into another service; members may not be held liable for such services.

Providers are responsible for reviewing the member's applicable benefits and payment policies before issuing an ANN; benefits may vary by contract—refer to the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for specific coverage instructions and appeals.

HCPCS Modifiers and Documentation Requirements

ANN/ABN-related HCPCS modifiersModifier

GA	Waiver of liability statement issued as required by payer policy, individual case
GU	Waiver of liability statement issued as required by payer policy, routine notice
GX	Notice of liability issue, voluntary under payer policy
GZ	Item or service expected to be denied as not reasonable and necessary

ANN documentation requirements

Service listedThe service/item believed to be not covered or not medically necessary must be specifically listed on the ANN.

Cost estimateAn estimate of the cost of the service/item must be included on the ANN.

Verbal review and Q&AThe ANN must be verbally reviewed with the member or representative and any questions answered prior to signing.

Delivered in advanceThe ANN must be delivered far enough in advance for the member to consider options and make an informed decision.

Copies and retentionA copy of the signed ANN is given to the member and the issuer must retain the original in the member's file.

What Providers Must Do

Denial Risk

Preauthorization denial substitutes for ANN

If a preauthorization request is denied and the member chooses to proceed with the service, the preauthorization denial notice serves as the required notification to the member. In that situation the provider must submit the claim with the appropriate modifier(s) and the claim will deny with member liability assigned for the service.

Prior Authorization

Issuing ANN for member liability

Providers must issue an Advance Notice of Noncoverage (ANN) to members before providing services that are non-covered or determined to be not medically necessary if the provider intends to hold the member financially responsible. The ANN must include: the specific service/item believed to be not covered or not medically necessary; an estimate of the cost; a verbal review with the member or their representative with questions answered prior to signing; delivery far enough in advance for the member to consider options; and a copy of the signed ANN given to the member with the issuer retaining the original in the member's file. An ANN must not be issued for services that are covered but not separately reimbursed or are bundled; providers should review member benefits and applicable policies before issuing an ANN. If an ANN is not given, the provider is financially liable for the service/item.

Billing Rule

Claim modifier submission rules

Submit claims with the appropriate HCPCS modifiers when an ANN has been issued or when notice of liability is otherwise applicable. Use GA or GZ only when an ANN has been issued and documentation is retained showing the ANN met the requirements (listed above). Use GU or GX for care that is typically excluded from coverage (for example, cosmetic procedures) to indicate notice of liability; such claims will deny and member liability will be assigned. Do not routinely append these modifiers or use them when the provider does not expect a denial — incorrect use may trigger audits and corrective action. These modifiers are not to be used for Medicare Advantage plans.

GA — Waiver of liability statement issued as required by payer policy, individual case
GU — Waiver of liability statement issued as required by payer policy, routine notice
GX — Notice of liability issued, voluntary under payer policy
GZ — Item or service expected to be denied as not reasonable and necessary

Key Terms and Modifier Definitions

ANN — Advance Notice of Noncoverage (ANN)

DefinitionAdvance Notice of Noncoverage (ANN) — notice given to members prior to services believed to be non-covered or not medically necessary.

Effect on claimsIf a member proceeds after receiving an ANN, provider may submit the claim with GA, GU, GX or GZ; if service is covered, claim pays and provider must refund any monies collected.

Not for bundled/covered-but-not-separately-reimbursed servicesANN must not be given for services that are covered but not separately reimbursed or are bundled; members may not be held liable for these.

GA — Waiver of liability (individual case)

ModifierGA

MeaningWaiver of liability statement issued as required by payer policy, individual case.

Use conditionShould be used only when a provider has issued an ANN and retains supporting documentation.

GU — Waiver of liability (routine notice)

ModifierGU

MeaningWaiver of liability statement issued as required by payer policy, routine notice.

Use caseUsed for care that is typically excluded from coverage; can provide notice of liability and will result in claim denial with member liability.

GX — Voluntary notice of liability

ModifierGX

MeaningNotice of liability issued, voluntary under payer policy.

Use caseUsed to provide notice of liability for typically excluded services; claim will deny with member liability assigned.

GZ — Expected denial (not reasonable and necessary)

ModifierGZ

MeaningItem or service expected to be denied as not reasonable and necessary.

Use conditionShould be used only when ANN issued and documentation retained; inappropriate use may trigger audit and corrective action.