CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Advanced Notice of Noncoverage (ANN) / ABN modifiers (GA/GU/GX)

This policy governs use of HCPCS modifiers GA, GU, and GX to document Advance Notice of Noncoverage (ANN)/ABN and allocate member liability for noncovered or denied services for Blue Cross Blue Shield - Rhode Island members and applies to providers submitting claims and obtaining member notice/consent.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAdvanced Notice of Noncoverage (ANN) / ABN modifiers (GA/GU/GX)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionIf preauthorization is denied and the member elects to proceed, submit the claim with the applicable modifier(s) to assign member liability even though an ANN is not required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3modifiers discussed (GA, GU, GX)

Not for Medicare Advantageexplicit exclusion note

Multiplepublication notices

Member Liability and Provider Notice

Member liability and provider notice criteria

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ALL of the following

ALL of the following
- ANN must specifically list the service/item believed to be not covered or not medically necessary.
- ANN must include an estimate of the cost of the service/item.
- ANN must be delivered far enough in advance for the member to consider options and make an informed decision.
- ANN must be verbally reviewed with the member or the member's representative and any questions answered prior to signing.
- A signed copy of the ANN must be provided to the member and the issuer must retain the original in the member's file.
ONE of: When preauthorization/authorization is denied and the member elects to proceed, the denial notice serves as notification (an ANN is not required); provider must still submit the claim with the applicable modifier(s) to assign member liability.
ONE of: GU or GX may be used to provide notice of liability for care typically excluded from coverage (for example, cosmetic services); use of these modifiers indicates member liability will be assigned for the service.

ALL of the following

Providers must review the member's applicable benefits and medical/payment policies before issuing an ANN; it is incorrect to file GA/GU/GX routinely or when the provider does not expect a denial.
If a service is covered but not separately reimbursed or is bundled, an ANN must not be given and members may not be held liable for those services.
If an ANN is not given for a non‑covered service, the provider is financially liable for the service/item.
Inappropriate use of the GA modifier may result in audit of the provider's records and corrective action; if a modifier is appended to a service that is covered, the claim will pay consistent with the member's benefit and the provider is responsible for refunding any monies collected from the member for a covered service.

Actions, Documentation, and Billing Rules for Providers

Denial Risk

Proceeding after a preauthorization denial

If a service/item preauthorization (prior authorization) is denied and the member elects to proceed with the service despite the denial, the written denial notice functions as the required advance notice to the member. In that case an Advance Notice of Noncoverage (ANN) is not required. The provider must still submit the claim with the appropriate modifier(s) (for example GA, GU, or GX) to indicate member liability, and the claim will adjudicate with member liability assigned for the service.

Submit the claim with the applicable modifier(s) even if an ANN was not provided because the prior authorization was denied.
The prior-authorization denial notice serves as notification to the member; no separate ANN needed when member elects to proceed.
Adjudication will assign member liability for the service when the denial notice substitutes for an ANN.

Documentation Required

Requirements for GA modifier / ANN

HCPCS modifier GA may only be used when the provider has issued an Advance Notice of Noncoverage (ANN) and retained documentation that demonstrates all required elements. Providers who use GA without a proper ANN, or use GA routinely when not appropriate, risk audit and corrective action. Modifiers GU and GX are intended for care that is typically excluded from coverage (for example, cosmetic procedures) and may be used to indicate member liability when an ANN is provided or when a denial notice substitutes for an ANN (see above).

GA may only be used when a written ANN exists and the provider retains the signed ANN in the member's file.
ANN must specifically list the service/item believed to be not covered or not medically necessary.
ANN must include an estimate of the cost of the service/item.
ANN must be delivered in sufficient time for the member to consider options and make an informed decision and must be verbally reviewed with the member or representative; questions must be answered prior to signing.
A copy of the signed ANN must be given to the member and the issuer must retain the original.
ANN is not required (and GA should not be used) if the service is covered but not separately reimbursed or is bundled into another service — members may not be held liable for bundled or covered services.
If an ANN is not given for a non-covered service, the provider is financially liable for the service/item.
Inappropriate or routine use of GA without meeting ANN requirements may result in audit and corrective action; providers should verify member benefits and payment policies before issuing an ANN.

Key Terms and Modifier Definitions

ANN / ABN — definition and required contents

DefinitionAdvance Notice of Noncoverage (ANN) / Advanced Beneficiary Notice (ABN): a written notice to the member listing the service or item believed to be not covered or not medically necessary, including an estimate of the cost; must be delivered in advance, verbally reviewed with the member (questions answered), and a signed copy provided to the member with the issuer retaining the original in the member's file.

PurposeNotify the member that the service/item may not be covered and to document the member's informed decision to proceed (which may assign financial liability to the member if requirements are met).

Required contentsService/item specifically listed and an estimate of the cost must be included on the ANN.

Timing and deliveryANN must be delivered far enough in advance for the member to consider options and make an informed decision; it must be verbally reviewed before signing and a copy given to the member.

Provider responsibilityProvider must retain the original signed ANN in the member's file; if an ANN is not given for a non-covered service, the provider is financially liable for the service.

GA — HCPCS modifier (individual-case waiver of liability)

ModifierGA

DefinitionWaiver of liability statement issued as required by payer policy for an individual case; used when a provider has issued an ANN and retains documentation supporting ANN requirements.

Documentation requirementsWhen GA is used the provider must retain documentation showing the service was listed on the ANN, cost estimate provided, ANN delivered in advance, verbally reviewed with questions answered, and a signed copy given to the member.

GU — HCPCS modifier (routine-case waiver of liability)

ModifierGU

DefinitionWaiver of liability statement issued as required by payer policy for a routine notice; applicable for ANN/ABN situations involving routine noncoverage notices.

Appropriate useGU may be used for care that is typically excluded from coverage to provide notice of liability and assign member liability for the service; should not be filed routinely when provider does not expect denial.

GX — HCPCS modifier (voluntary notice of liability)

ModifierGX

DefinitionNotice of liability issued voluntarily under payer policy; used to notify the member that liability may apply for services typically excluded from coverage.

Appropriate useGX can be used to provide notice of liability for services typically excluded from coverage (for example cosmetic procedures); the claim will process with member liability assigned when applicable.