CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Statutorily Non‑Covered Services for Medicare Advantage Members

Defines services excluded from Medicare coverage by statute and explains requirements for Medicare Advantage plans and contracted providers regarding notification, member liability, claim modifiers, and Notice of Denial of Medical Coverage.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyStatutorily Non‑Covered Services for Medicare Advantage Members

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionContracted providers must obtain a plan-issued Notice of Denial of Medical Coverage before providing a statutorily excluded service if seeking to transfer liability to the member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

examples listedexamples listed

Notice requiredNotice required

ABN prohibitedABN prohibited

modifier usemodifier use

Coverage criteria and scope

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Coverage criteria and requirements

Covered with conditions and documentation requirements for statutorily non‑covered services under Medicare Advantage; members may be liable only when plan and CMS requirements are met.

ALL of the following

A: If the plan EOC clearly states the service is never covered, the EOC constitutes notification and the member may be held liable; providers should submit the claim with appropriate G modifiers (GX and/or GY).
B: If the EOC is unclear or the service may be provided through a supplemental benefit, follow the supplemental benefit rules in the EOC or contact Provider Services for guidance; member liability depends on the EOC/vendor rules and plan determination.

ALL of the following

A Plan‑specific Notice of Denial of Medical Coverage must be issued by the Medicare Advantage plan prior to the service to transfer liability to the member.
The contracted provider must call Provider Services to request the Notice; the plan will mail the letter to the member and fax a copy to the provider.
The NMDC advises the member the service is not covered, that they are liable for payment, and provides appeal rights; the plan must issue the letter (providers may not issue their own template).
If the NMDC is not provided to the MA member, the claim may be denied to the provider and the provider will be held financially responsible; therefore file claims for services rendered with documentation and appropriate modifiers even if NMDC is issued.

ALL of the following

Submit claims for all services rendered; include the NMDC with the claim when one has been issued and attach supporting documentation as usual.
File claims with the appropriate G modifier(s) to indicate statutorily non‑covered status: use GX to indicate an item or service is statutorily non‑covered; use GY when the EOC clearly never covers the item or when a Notice of Non‑Coverage has been issued. GA and GZ are not appropriate for statutorily excluded services per this policy.

ALL of the following

Contracted providers must ensure CMS notification requirements are met before obtaining member liability; if providers fail to follow CMS guidelines or do not obtain the plan‑issued NMDC, claims will be denied to the provider and the member cannot be held financially liable.
Do not use the Medicare Advanced Beneficiary Notice (ABN) for Medicare Advantage members; the plan‑issued Notice of Denial of Medical Coverage must be used instead.

Operational note: When requesting a Notice of Denial of Medical Coverage, contact Provider Service/Customer Service and provide member and service details so the plan can issue the NMDC; submit claims with documentation and appropriate G modifiers to preserve appeal rights.

Required modifiers and coding details

G Modifiers for statutorily excluded servicesModifier

GX	Item or service statutorily non-covered or not a Medicare benefit
GY	Item or service statutorily non-covered or not a Medicare benefit (use when Notice of Non-Coverage issued or when EOC clearly never covers)
GZ	Expected Medicare denial as not reasonable and necessary (not appropriate for statutorily excluded services)
GA	Expected Medicare denial as not reasonable and necessary (not appropriate on statutorily excluded services)

Required information to request Notice of Denial

Member identifierMember ID including prefix

Service dateDate of Service

Member demographicMember's name and DOB

Provider identifiersServicing provider TIN and fax number

Ordering/provider detailsOrdering physician name, address and TIN

Servicing facility detailsServicing facility name, address and TIN

Clinical codingCPT code(s) and diagnosis

Actions providers must take

Denial Risk

Obtain Notice of Denial of Medical Coverage

If a member would like a statutorily excluded service, the member must be notified in advance that the service is not covered and provided a plan-specific Notice of Denial of Medical Coverage (NMDC). The contracted provider must request the NMDC from the Medicare Advantage plan (call Provider Service Department). The plan issues the NMDC to the member and will fax a copy to the provider. The NMDC advises the member that the service is not covered, that they are liable for payment if they choose to proceed, and informs them of their appeal rights. The NMDC must be issued by the plan — providers may not create their own template.

Provider should call Provider Service Department and provide: Member ID (with prefix), Date of Service, Member name and DOB, Servicing provider/TIN, Ordering physician/address/TIN, Servicing facility/address/TIN, Fax number for servicing provider, CPT code(s), Diagnosis.
If NMDC is not provided to the MA member prior to the service, claims may be denied and the provider will be held financially responsible.
The NMDC should be submitted with the claim when available; claims must still be filed for services rendered even when NMDC issued.

Billing Rule

Prohibition on ABN — use Plan-issued NMDC

Do not issue an Advanced Beneficiary Notice (ABN) to Medicare Advantage members. CMS prohibits ABNs for MA enrollees. Instead, use the plan-issued Notice of Denial of Medical Coverage (pre‑determination denial). Contracted providers are considered agents of the MA plan and must follow MA-specific liability-notice procedures.

Billing Rule

Claim submission and G modifier guidance

When submitting claims for statutorily excluded services, use the appropriate G modifiers per CMS guidance: use GX for statutorily non‑covered services; use GY when the item/service is statutorily non‑covered and proper notification has been secured (NMDC or clear EOC); when the EOC clearly states the item is never covered, submit with GY. Do not use GA or GZ for statutorily excluded services. Follow the member's Evidence of Coverage and the plan's filing instructions; submit the NMDC with the claim when issued.

GX = statutorily non‑covered or not a Medicare benefit (use for statutorily excluded services).
GY = statutorily non‑covered and proper notification has been secured (use when NMDC issued or EOC clearly states non‑coverage).
Do not use GA or GZ for statutorily excluded services.

Key definitions

Statutorily non-covered services (examples)

Eye refractionsEye refractions with the Medicare covered vision exam

Hearing aidsHearing aids

Custodial careCustodial care

Routine dental servicesRoutine dental services

Routine vision servicesRoutine vision services

Services outside USService not provided within the United States

Notice of Denial of Medical Coverage (pre-determination denial)

DefinitionA plan-issued letter advising the member the service is not covered (non-covered item or service) and outlining the member's liability and appeal rights

PurposeTo notify the member in advance of non-coverage so the member can decide whether to proceed and to document liability transfer when issued prior to service

IssuanceThe contracted provider requests the letter from Provider Service; the plan issues the letter to the member and faxes a copy to the provider

Claim handlingThe Notice should be submitted with the claim; claims for rendered services should still be filed with documentation and appropriate G modifiers

ABN (Advanced Beneficiary Notice)

DefinitionAdvanced Beneficiary Notice (ABN): a notice used in Medicare Fee‑For‑Service to inform beneficiaries when services may not be paid by Medicare

Prohibition for MACMS prohibits the use of the ABN for Medicare Advantage members; MA plans must use the plan-issued Notice of Denial of Medical Coverage instead

ScopeABN is not used for items or services provided under Medicare Advantage or Medicare Part D