CurrentMolina HealthcarePolicy N/A

Advanced Beneficiary Notice (ABN) and Related Modifiers for Reimbursement

Defines Molina Healthcare's reimbursement guidance for billing non-covered services using Medicare ABN-related modifiers and documentation requirements; affects Molina providers submitting claims for Medicare and Medicaid members.

Policy Summary

PayerMolina Healthcare

PolicyAdvanced Beneficiary Notice (ABN) and Related Modifiers for Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionApply appropriate ABN modifiers (GA, GX, GY, GZ) and maintain documentation with valid diagnosis codes to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4ABN-related HCPCS modifiers described (GA, GX, GY, GZ)

Claims may be deniedDenial / recovery risk noted

3Policy revision entries

Chapters citedCMS chapters cited

Billing and Coverage Criteria for Non-Covered Services

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.

Billing and Coverage Criteria for Non-Covered Services

When billing for services where Medicare coverage is uncertain or not applicable, providers should follow these rules:

Providers must maintain proper documentation of medical necessity and valid diagnosis codes for claim reimbursement.

Charges submitted without supporting evidence of medical necessity or the correct diagnosis codes will not be considered for claim payment.

Molina may deny or not factor such charges into claim payment calculations.

ALL of the following

GA: Valid and signed ABN on file for a service not medically necessary (Medicare considers medical necessity; if not medically necessary, patient liability; offers appeal rights).
GX: Valid and signed ABN on file for a service not included in Medicare's benefits (Medicare does not review medical necessity; assigns patient liability; offers appeal rights).
GY: ABN optional for statutorily excluded items or services (Medicare does not review medical necessity; assigns patient liability).
GZ: No ABN on file, but Medicare requires one to change patient liability (Medicare does not review medical necessity; assigns provider liability; offers appeal rights).

Claims billed inaccurately or without required documentation may be denied or subject to recovery; Molina may review and recover overpayments.

Listing of a code or modifier in this policy does not guarantee coverage; coverage is determined by the member benefit document and applicable law.

Medicare ABN Modifiers and Documentation Requirements

Medicare ABN ModifiersHCPCS

GA	Valid and signed ABN on file for a service not medically necessary
GX	Valid and signed ABN on file for a service not included in Medicare's benefits
GY	ABN is optional for statutorily excluded items or services
GZ	No ABN on file, but Medicare requires one to change patient liability

Documentation requirement

Documentation requirementCharges submitted without supporting evidence of medical necessity or the correct diagnosis codes will not be considered for claim payment.

Effect of missing documentationClaims not billed accurately may be denied or subject to potential recovery by Molina Healthcare.

Reimbursement basisReimbursement is determined by the appropriate fee schedule or the provider contract agreement.

Molina review rightsMolina Healthcare reserves the right to review all claim payments and recover any overpaid amounts identified based on contractual rate.

ABN Modifiers and Provider Documentation Responsibilities

Billing Rule

Use ABN Modifiers (GA/GX/GY/GZ) and Provide Required Documentation

Use the ABN-related modifiers GA, GX, GY, and GZ as appropriate to indicate ABN status and patient/provider liability and to facilitate claims processing; ensure proper supporting documentation and valid diagnosis codes accompany billed services.

Apply GA when a valid, signed ABN is on file for a service not medically necessary (Medicare considers the claim for medical necessity; if not medically necessary, patient liability applies).
Apply GX when a valid, signed ABN is on file for a service not included in Medicare benefits (Medicare does not review medical necessity; patient liability applies).
Apply GY for statutorily excluded items or services (ABN optional; Medicare does not review medical necessity; patient liability applies).
Apply GZ when no ABN is on file but Medicare would require one to change patient liability (Medicare does not review medical necessity; provider liability may apply).
Submit charges only with supporting evidence of medical necessity and correct diagnosis codes; charges without this documentation will not be considered for claim payment.
Claims billed inaccurately or without required documentation may be denied or subject to recovery; Molina may review and recover overpayments.

Key Definitions

CMS

AcronymCMS = Centers for Medicare and Medicaid Services

UsageReferenced for claims processing guidance (see CMS Claims Processing Manual chapters cited in policy).

AuthorityFederal agency whose manuals and guidance inform Molina's reimbursement and claims processing rules.

CPT

AcronymCPT = Current Procedural Terminology

PurposeStandard coding terminology used to describe medical, surgical, and diagnostic services for billing and claims processing.

ReferenceDefined in policy's Definitions section to support accurate coding and reimbursement determinations.