Denial Code CO 34: Insured has no coverage for newborns.

Health care services for newborns are among the most expensive medical expenses. According to Parents.com, birth can cost between $2,000-$4,500 dollars depending on the method of delivery without complications. You would not only have to pay for prenatal, delivery, and postnatal care out-of-pocket, but for all care that your newborn receives after birth.

Without insurance coverage, you could end up with expensive medical bills that can create a financial strain on your growing family. Getting newborn coverage in the first 30 days will help you protect both you and your baby.

Does my individual or family plan automatically cover my new baby?

After your baby is born, your child is covered for the first 30 days of life as an extension of you, the mother, under your policy and deductible.

Starting on day 31, this extension of coverages ends. While maternity care (both pre and postnatal) and some health care services for children are essential benefits that are covered by all marketplace plans, health insurance for babies is not included as an essential benefit. To get health insurance at this time, you must enroll in or change your health insurance plan.

How Can You Make Sure Your Newborn Is Covered?

Remember that your infant should automatically receive coverage for at least the first 30 days of life. You’ll want to ensure your baby gets covered after that—the cost of essential immunizations, screenings, and other necessary medical exams can mount up.

The earlier you start inquiring about newborn health insurance to continue coverage after day 30, the better. Check in with your insurance provider about the terms of their special enrollment period for qualifying life events.

If you’re currently not covered by any plan, several government programs can cover essential health services for your infant.

What Programs Help With Health Insurance for Newborns?

Several programs can help if you’re under a certain income threshold. Remember that you should disregard the standard open enrollment periods, as you will qualify for special enrollment after the birth of your baby. These include:

Affordable Care Act (ACA)

Where it concerns newborns, the ACA—better known by the nickname “Obamacare”—can add protective coverage to your existing health plan and reduce existing costs.

The majority of insurance providers must abide by the ACA, where it concerns providing some essential services after birth without charging you extra. The exact items eligible for coverage vary from state to state but can include the following services for newborns:

• Blood screening
• Sickle cell screening
• Hypothyroidism screening
• PKU screening
• Fluoride varnish to protect teeth
• Oral health risk assessment
• Iron supplements

ACA also covers ongoing care throughout your child’s life, such as developmental and behavioral screening and immunization up to age 18. To enroll in the ACA, you can apply on Healthcare.gov—any US citizen is eligible.

Children’s Health Insurance Program (CHIP)

If you’re not eligible for Medicare, CHIP is a comprehensive program you can consider that covers newborn health insurance. Your child will receive coverage up to the age of 18, and you can also receive prenatal checkups and care. Your newborn will also benefit from coverage for:

• Routine checkups
• Immunizations
• Vision care
• Dental care
• Doctor visits
• Prescription drugs
• Laboratory tests
• X-ray services
• Emergency services
• Doctor appointments

Although routine doctor’s visits and checkups for your infant are wholly covered by CHIP, as is dental when your child grows older, your state may charge you a monthly premium fee for CHIP coverage—but it shouldn’t total more than 5 percent of your yearly income.

In a Nutshell

Pregnant parents have enough to worry about without adding health insurance for newborns to the list. You’ll have 30 to 60 days to add your baby to your health plan, depending on whether you’re insured through your employer, or you pursue the 60-day special enrollment period in your state.

Suppose your income is below a certain level. In that case, you might be able to take advantage of the Affordable Care Act (ACA), Medicaid, or the Children’s Health Insurance Program (CHIPs) to secure coverage. Ideally, it would be best if you started looking into your options before your little one’s birth.

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Denial Code CO-9: Diagnosis Code is Inconsistent with the Patient’s Age

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Denial Code CO 8: The procedure code is inconsistent with the provider type/specialty (taxonomy)

This needs to go to whomever in your system set up the billing system. They need to check the provider taxonomy codes to see if that provider is correctly set up for the type of service that was being done. Every provider has a number of taxonomy codes to choose from for the types of service they perform. If the correct one is not registered, payment will be denied for certain types of care.

What is a Taxonomy?

In a broad sense the science of classification, but more strictly the classification of living and extinct organisms—i.e., biological classification. The term is derived from the Greek taxis (“arrangement”) and nomos (“law”). Taxonomy is, therefore, the methodology and principles of systematic botany and zoology and sets up arrangements of the kinds of plants and animals in hierarchies of superior and subordinate groups. Among biologists the Linnaean system of binomial nomenclature, created by Swedish naturalist Carolus Linnaeus in the 1750s, is internationally accepted.

Popularly, classifications of living organisms arise according to need and are often superficial. Anglo-Saxon terms such as worm and fish have been used to refer, respectively, to any creeping thing—snake, earthworm, intestinal parasite, or dragon—and to any swimming or aquatic thing. Although the term fish is common to the names shellfish, crayfish, and starfish, there are more anatomical differences between a shellfish and a starfish than there are between a bony fish and a man. Vernacular names vary widely. The American robin (Turdus migratorius), for example, is not the English robin (Erithacus rubecula), and the mountain ash (Sorbus) has only a superficial resemblance to a true ash.

What is a taxonomy code?

Taxonomy Codes are an administrative code set for identifying the provider type and area of specialization for healthcare providers. They are alphanumeric and are ten characters in length. Taxonomy codes allow providers to identify their specialty. A provider can have more than one taxonomy code. When a provider applies for an NPI number, he or she must select at least one taxonomy code indicating their specialty.

On Call Scenario:

1. Claim denied as the procedure code is inconsistent with provider type/specialty
2. May I get the denial date?
3. What is the exact reason for denial?
4. Provider specialty is not allowed to perform this service

• Check the provider specialty on NPPES Website (Just enter rendering provider’s NPI  in NPI Number section and click on ‘Search’ Button. you will get provider  specialty under ‘Primary Taxonomy Section)
• Verify specialty with CPT
• IF Different (May I have the claim# & Call Ref#)
• IF Same (Ask rep to send claim for reprocessing)

5. At which box# on claim form taxonomy code is missing? IF No: May I have the claim# & Call Ref#

• Check the claim form if taxonomy code is available or not
• IF Yes (Ask for clarification from rep and send claim back for reprocessing)
• Rep agrees, IF Yes:  What is the TAT for reprocessing? IF No: May I have the claim# & Call Ref#

Important Note:

• In CMS 1500 form, rendering provider’s taxonomy code is available on box# 24J above NPI and billing provider’s taxonomy code is available on box# 33b.
• When taxonomy code is available in CMS 1500 and rep still not able to find from their end then resubmit the claim again, information may be missing due to some error.
• When taxonomy code is not available on claim form then resubmit the claim to check taxonomy code still going on claim form or not. If it is still missing then inform the same to client.

What are the Healthcare Provider Taxonomy Codes (HPTC)?

Where may I obtain a copy of the codes? The Healthcare Provider Taxonomy Codes (HPTC) are a HIPAA standard code set named in the implementation specifications for some of the ASC X12 standard HIPAA transactions. The “Healthcare Provider Taxonomy Code” is a situational data element in the 4010 X12 Implementation Guides and the 5010 X12 TR3 Reports for the 837 Professional and Institutional. If the Taxonomy code is required in order to properly pay or process a claim/encounter information transaction, it is required to be reported. Thus, reporting of the Healthcare Provider Taxonomy Code varies from one health plan to another. The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are alphanumeric and are 10 positions in length. These codes are not “assigned” to health care providers; rather, health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. If a health care provider has more than one taxonomy code associated with it, a health plan may prefer that the health care provider use one over another when submitting claims for certain services.

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Denial Code CO 19 – This is a work-related injury/illness and thus the liability of the Worker’s Compensation Carrier

Insurance company will deny the claim with CO 19 denial code – This is a work related injury/illness and thus the liability of the Worker’s Compensation Carrier, when the services pertain to work related injury and should be submitted to workers compensation carrier.

What is Workers Compensation?

Workers compensation insurance covers the medical benefits and wages to employees for work related injuries or illness.

Features of Workers Compensation Program:

• This plan covers only the diseases, infections or injuries that are work related
• No patient’s responsibility.
• Employer pays the premium as well as the annual deductible amount.
• No coverage for dependents.

Reports to be submitted for Workers compensation:

• Accident Report
• First Investigation Report
• Medical Records
• Witness Reports
• Employers Reports
• Ombudsman’s Reports

We need to first check the below steps to resolve the issue:

• First see is there a claim number available in place of insurance ID.
• Review other DOS with same Procedure/Diagnosis code to determine if they were processed as medical or injury related.
• Review patient medical records to determine if the service pertains to injury.
• Was the claim submitted to correct Payer?
• Review is there any note stating this is under litigation?
• If the claim Worker Comp/Auto accident related, update the appropriate details and submit the claim with medical records (Important Note: Resubmit all open claims of this patient with same CPT/DX combination to worker compensation carrier).
• If not available, then patient needs to be contacted for correct information.

Call the claim department and ask the following questions:

1. Get the received date and the date they have denied the claim?
2. Review the diagnosis code and Medical records to ascertain that its work related injury or not?
3. If you come across the claim billed is work related injury/illness, then update the worker compensation carrier details and submit the claim.
4. If the claim billed is not work related injury/illness and if rep refused to send the claim back for reprocessing, take appeal limit, address or fax# (Appeal the claim with medical records.

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Payers will deny the claims with CO 26 Denial Code – Expenses incurred prior to coverage, whenever the providers perform health care services to patient prior to the insurance coverage starts.

What steps needs to be taken?

• Review other claims in the application within a span of 30 days, to see if any claims were paid and find out whether we have receive payment from the same insurance or not?
• If the paid claim has same insurance ID, then check the eligibility to confirm the patient was effective, eligible and active at the time of health care service rendered? If the above condition is satisfied, call the payer claims department and have the claim reprocessed.
• If not, check the application was there other insurance involved in paying those claims. If yes, submit the claim to the valid insurance which is eligible and active at the time of service provided.
• Review previous notes in the application to see any updates of new policy details.
• Review path for any scanned copies of insurance information in the application.
• If any of the new insurance information available, check eligibility of new insurance, update the insurance details in application, and then resubmit the claim to the appropriate insurance for reimbursement.
• If not, bill the patient or place a call to patient requesting active insurance details.

Call the Claims department and ask the following question to resolve the CO 26:

1. First get the date of received and denial of the claims?
2. Next, check the effective date of the patient health insurance policy to know when the insurance coverage starts to take the necessary action as per the denials?
3. Check the termination date of the insurance policy to know when the health insurance coverage of patient is inactive and take necessary action?
4. After verification with representative, if patient policy was effective, eligible and active for date of service, then send the claim back for reprocessing.
5. If suppose patient was not effective, not eligible and not active at the time service provided, check with representative and find out any other health insurance details for particular patient which is active and eligible at the time of service rendered.
6. Finally, get the Claim number and Cal reference number of the denied claim from representative.

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Reasons for Non-covered Charges:

• Diagnosis or service (CPT) performed or billed are not covered based on the LCD.
• Services not covered due to patient current benefit plan.
• It may be because of provider contract with insurance company.

So when you come across CO 96 – Non Covered Charges, the first thing is to check the remarks code listed with that denial to identify the correct denial reason.

Take a look at some of the important remark codes for Denial Code 96:

COMMON REASONS FOR DENIAL

The actual meaning for this denial is billing for services not covered under the contract. This could be differentiated between Providers’ and Patients’ Contract. All carriers have their list of Non-covered services mentioned in the Providers’ & Patients’ handbook / manual. This also includes Providers’ participation with the carrier and the patients’ choosing of one such provider who participates.

NEXT STEP

If billed incorrectly (such as inadvertently omitting a required modifier), request a reopening. If is for the KX, GA, GZ, or GY modifiers, you must request a redetermination request. Check Local Coverage Determination (LCD) documentation requirements for coverage and use of modifiers.

But most of times this denial is not able to be corrected.

If you are submitting non-covered services to receive a denial for secondary or supplemental insurance, ensure to bill services with the modifier GY, indicating “statutorily non-covered services.” Generally secondary insurance would cover these rejections.

CO 96 DENIAL CODE CATEGORIES

Non-Covered denial (CO 96) is grouped majorly under the following categories by the carriers:

PR 96 DENIAL CODE: PATIENT RELATED CONCERNS

When a patient meets and undergoes treatment from an Out-of-Network provider.

• Based on Provider’s consent bill patient either for the whole billed amount or the carrier’s allowable. Cross verify in the EOB if the payment has been made to the patient directly. If yes, please bill the patient without any delay.
• Prior verification notes should explain in detail for the front desk executive so that they could inform patient about provider’s participation. In most cases they would avoid seeing those patients except for an emergency need.
• Cross verify with the insurance if the payment would be made to the patient if the claims are filed. If yes, document the same in the notes and alert the front office to collect the calculated (calculate separately based on the CPT’s allowed amount) amount from the patient at the time of service.

CO 96 DENIAL CODE: PROVIDER RELATED CONCERNS

• Coding: ICD – LCD guidelines not met; Multiple procedures performed on the same day billed; Invalid POS/type billed; When a service is performed within a period of time prior to or after inpatient services; Invalid NDC code; Inclusive to primary procedure billed; or Invalid CPT billed and Others.
• When service is not related to Providers’ specialty: Inform provider about the procedure listed in the superbill and suggests an alternate active CPT code to be billed – to be done during coding and charge entry process itself before claim submission.
• Non-covered services listed by the carriers billed: List the services which are denied for the given reason from specific carriers and forward it to client for W/O approval. Note: Ensure that we have billed the CPTs correctly.
• If provider is not participating with the carrier: Credentialing process to be initiated and affected claims are to be compiled and sent for provider’s approval for W/O

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Denial Reason Code PR B9: Patient is enrolled in a Hospice.

Per Medicare guidelines, services related to the terminal condition are covered only if billed by the hospice facility to the appropriate fiscal intermediary (Part A). Medicare Part B pays for physician services not related to the hospice condition and not paid under arrangement with the hospice entity.
Check beneficiary eligibility prior to submitting claim to Medicare. Click here for ways to verify beneficiary eligibility and get hospice effective and/or termination date, if applicable.
You may also look up hospice provider information, including servicing provider number, by clicking here compressed file.

The following situations require a modifier be applied to the claim prior to submission.

• Attending physician not employed by, or paid under agreement with, the patient’s hospice provider:
• Claim should be submitted with modifier GV.
• If claim was submitted with the GV modifier, check patient’s file to verify that the attending physician is not employed by the hospice provider.
• Services not related to the hospice patient’s terminal condition:
• Claim should be submitted with modifier GW.
• If claim was submitted with the GW modifier, verify the diagnosis code on the claim and ensure services are not related to the patient’s terminal condition.
• If claim was submitted without the appropriate modifier, apply modifier and resubmit claim.

Common Reasons for Message

• Patient is enrolled in Hospice on date of service
  • Medicare Part B only pays for physician services not related to Hospice condition and not paid under arrangement with Hospice entity
• Patient’s Common Working File (CWF) has not been updated to show Hospice election has been revoked

Next Step

• Append Hospice modifier if appropriate
  • Modifier GV– Attending physician is not employed or paid under agreement by patient’s Hospice provider
  • Modifier GW– Condition not related to patient’s terminal condition
• Submit Appeal request – Items or services with this message have appeal rights

Items & Services Included in the Hospice Benefit 

The Medicare hospice benefit includes these items and services to reduce pain or disease severity and manage the terminal illness and related conditions:

• Services from a hospice-employed physician, nurse practitioner (NP), or other physicians chosen by the patient
• Nursing care
• Medical equipment
• Medical supplies
• Drugs to manage pain and symptoms
• Hospice aide and homemaker services
• Physical therapy
• Occupational therapy
• Speech-language pathology services
• Medical social services
• Dietary counseling
• Spiritual counseling
• Individual and family or just family grief and loss counseling before and after the patient’s death
• Short-term inpatient pain control and symptom management and respite care

Medicare may pay for other reasonable and necessary hospice services in the patient’s POC. The hospice program must offer and arrange these services

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Denial Reason Code B7  —-> This provider was not certified/eligible to be paid for this procedure/service on this date of service.

Remark Code: N570  —-> Missing/incomplete/invalid credentialing data.

This denial is received when the claim’s date of service is prior to the provider’s Medicare effective date or after his/her termination date, or when a procedure code is beyond the scope of the provider’s Clinical Laboratory Improvement Amendment (CLIA) certification, or a laboratory service is missing a required modifier.

Submit claims for services rendered when the provider had active Medicare billing privileges.

Review the Medicare Remittance Advice (RA), and verify the date of service.

• If the date of service is not correct, follow procedures for correcting claim errors.
• If the date of service is correct, there may be an issue with the provider’s Medicare effective or termination date.
• View enrollment information through the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) and confirm provider’s Medicare effective date. Click here external link for more details.

Note: The provider’s Medicare effective date can be retroactive up to 30 days from receipt of application, or a future date, up to 60 days from receipt of application.

• If you require additional assistance, you may contact Provider Enrollment.
Submit claims for laboratory services within the scope of the provider’s CLIA certification.
• Verify service/procedure code is listed as approved under the scope of the provider’s certification
Refer to the List of Waived Tests external pdf file from the CMS website to determine which codes require the modifier QW (CLIA waived tests).
• If the procedure code is not correct, or the procedure code modifier is missing, follow procedures for correcting claim errors.
Make the necessary correction(s), and resubmit the claim. Submit the corrected line only. Resubmitting the entire claim will cause a duplicate claim denial.

Resolution

• HCPCS modifier QW must be submitted with certain clinical laboratory tests that are waived from the Clinical Laboratory Improvement Amendments of 1988 (CLIA) list. The Food and Drug Administration (FDA) determines which laboratory tests are waived.
• Note: Not all CLIA-waived tests require HCPCS modifier QW
• Determine if the CPT code is a waived test by accessing the CMS CLIA Web page
• Palmetto GBA will publish information on tests newly classified as ‘waived’ on our Web site. Please note, the list of CLIA-waived procedures is updated as often as quarterly.
• The CLIA certificate number is also required on claims for CLIA waived tests. Submit this information in Loop 2300 or 2400, REF/X4, 02 for electronic claims. For paper claims, submit the CLIA certification number in Item 23 of the CMS-1500 claim form.
• Access complete instructions for correctly submitting HCPCS modifier QW in the Palmetto GBA Modifier Lookup tool:

o Jurisdiction 1: Select ‘Articles’ on the left side of the Palmetto GBA Web page

o Ohio, South Carolina and West Virginia: Select ‘Browse by Topic’ on the left side of the Palmetto GBA Web page.

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Gramm-Rudman-Hollings Act, officially the Balanced Budget and Emergency Deficit Control Act of 1985, U.S. budget deficit reduction measure. The law provided for automatic spending cuts to take effect if the president and Congress failed to reach established targets; the U.S. comptroller general was given the right to order spending cuts. Because the automatic cuts were declared unconstitutional, a revised version of the act was passed in 1987; it failed to result in reduced deficits. A 1990 revision of the act changed its focus from deficit reduction to spending control.

“Sequestration” is a process of automatic, largely across-the-board spending reductions under which budgetary resources are permanently canceled to enforce certain budget policy goals. It was first authorized by the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA, Title II of P.L. 99-177, commonly known as the Gramm-Rudman-Hollings Act). It was applied again by Congress to affect current budgetary policy through the Budget Control Act of 2011 and the American Taxpayer Relief Act (ATRA) of 2012.

The Sequester began officially on March 1, 2013. However, some of its effects will not be felt immediately. The Centers for Medicare and Medicaid Service announced on March 8, 2013 that if Congress does not act to stop the spending cuts before April 1, payments for all Medicare services provided on or after that date will be reduced by 2 percent. ACP is hopeful that Congress will arrive at a solution to avoid the cuts before hospitals and physicians feel them.

However, it is important to note that the Medicare provider cuts are treated differently under this law than they would be for a typical January 1st change to the physician fee schedule conversion factor. According to the Congressional Research Service, percentage payment reductions made under Medicare Parts A and B will be made to individual payments to providers for services (e.g., hospital and physician services) rather than to fee schedule allowable charges. Therefore, it has been ACP’s understanding, which has now been confirmed by CMS, that for Part B services provided under assignment (i.e., when the patient agrees to have Medicare pay the physician directly), the reduced Medicare payment would be considered payment in full to the physician (meaning that the physician’s payment receives the 2 percent reduction), but the patient’s cost sharing amount remains unchanged. That is, the physician would continue to collect from the Medicare beneficiary the usual 20 percent co-insurance that applies despite the 2 percent cut. To illustrate, for a service for which Medicare allows $100, the physician would continue to collect $20 from the beneficiary (20 percent of $100). But during sequestration, the physician’s payment from Medicare will be $80.00 (or 80 percent of $100) minus the 2 percent reduction, resulting in a physician payment of $78.40.

It should be noted that Medicare’s payment to beneficiaries for unassigned Part B claims is subject to the 2 percent reduction. CMS encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.

While physician payments (and payment to other Medicare providers, such as hospitals, health plans, and drug plans) will be cut, Medicare’s benefit structure generally remains unchanged (i.e., beneficiaries would not see a change in their Medicare coverage). Spending for certain Medicare programs and activities is exempt from sequestration and are therefore not reduced under a sequestration order. These include (1) Part D low-income subsidies; (2) the Part D catastrophic subsidy; and (3) Qualified Individual (QI) premiums.

The College is waiting to receive additional formal clarification and instructions from CMS regarding how physician claims will be affected by sequestration. In addition to claim payments, the College has raised questions regarding a number of additional payment issues that will likely be affected. For example, the College has recently learned that Elizabeth Holland, Director of the HIT Initiatives Group in CMS’ Office of E-Health Standards & Services, has confirmed that Medicare meaningful use payments will be subject to the 2 percent mandatory cut to Medicare under budget sequestration. Participants receiving these payments under Medicaid will not be subject to the reduction. Other issues that continue to require clarification from the agency include:

• How will sequestration affect the following programs linked to Medicare Part B claims—the Medicare Primary Care Bonus Program, the Electronic Prescribing (eRx) Incentive Program, and the Physician Quality Reporting System (PQRS) Program?
• How will sequestration effect the Medicaid Parity payments that began this year for physicians delivering designated primary care services?

ACP is continuing to wait for further details of the Medicare sequester implementation and its impact on our members; the College will update this article as more information becomes available.

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What do you do when you are presented with a patient who needs treatment but

• The patient’s insurance company will not pay for the services?
• Can you provide the services anyway?
• Who will pay for them?
• How do you collect payment for such services?

If the patient consents to receive the services in spite of the insurance company’s refusal to pay for such services, you will likely be able to bill the patient directly. However, in order to do so, there are certain requirements that you must satisfy.

Reason for Non-Coverage

Several reasons exist for why a particular service may not be covered by Medicare, Medicaid or a commercial insurance provider. Medicare specifically identifies four categories of items and services that are not covered, which are generally applicable to commercial payers as well. The four categories are:

1. Services that are not medically reasonable and necessary.

Services that are not medically reasonable and necessary to the patient’s overall diagnosis and treatment are not covered. To be considered medically necessary, the services must meet specific criteria defined by national coverage determinations and local coverage determinations. For each service billed, you must identify the specific patient symptom or complaint that necessitates the service.

2. Non-covered services.

Some services are just not covered by certain payers. These include, but are not limited to, services furnished outside the U.S., certain routine physical checkups, eye examinations, eyeglasses and lenses, hearing aids and examinations, certain immunizations, personal comfort items and services, custodial care, and cosmetic surgery.

3. Services denied as bundled or included in the basic allowance of another service.

services that are denied as bundled or included in the basic allowance of another service include fragmented services that are part of the basic allowance of the initial service, in addition to prolonged care, physician standby services, certain case management services and supplies included in the basic allowance of a procedure.

4. Services reimbursable by other organizations or furnished without charge.

Some services are reimbursable under automobile, no-fault or liability insurance, or workers’ compensation programs and, therefore, are not covered by Medicare. Also, payment will not be made for the following: certain services authorized or paid by a government entity; services for which the patient, another individual or an organization has no legal obligation to pay for or furnish (e.g., X-rays or immunizations gratuitously furnished to patient without regard to patient’s ability to pay and without expectation of payment from any source); defective medical equipment; medical devices under warranty if they are replaced free of charge by the warrantor; or if an acceptable replacement could have been obtained free of charge under the warranty but was purchased instead.

There are three modifiers to consider when dealing with non-covered services: 

• GX – Notice of liability issued, voluntary payer policy. A -GX modifier should be attached to the line item that is considered an excluded, non-covered service. The -GX modifier indicates you provided the notice to the beneficiary that the service was voluntary and likely not a covered service.
• GY – Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, and is not a contract benefit. If you do not provide the beneficiary with notice that the services are excluded from coverage, you should append modifier -GY to the line item. Modifier -GY indicates a notice of liability (ABN) was not provided to the beneficiary.
• GZ – Item or service expected to be denied as not reasonable and necessary. Modifier -GZ should be added to the claim line when it is determined an ABN should have been obtained, but was not.

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