Resolved GA modifier for Medicare Patients

[ManaleK_85648]

When Medicare receives a claim and shows modifier GA (patient is responsible in case Medicare denied the claim) on it, Is Medicare not going to review the claim and automatically going to deny because shows the modifier GA on it or Is Medicare going to review the claim and if has medical necessity then will pay even if has the modifier GA on it?

 

[MichelleJ_83786]

This is from the Pub 100-04 Medicare claims processing Manual. How I understand it with the GA modifier is that the provider and patient understand that it will be denied as non-covered because it's not reasonable or necessary but that you have an ABN on file. The ABN must be on file signed by the patient prior to the services being billed to Medicare. The patient must know the exact amount of the cost and this should be reflected on the ABN.

The GA modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary. (See http://www.cms.hhs.gov/medlearn/refabn.asp for additional information on use of the GA modifier and ABNs.)

 

[Alicia]

Having an ABN is important. It covers your bases. You do not have to provide the exact cost however you need to have expected cost.

 

[MichelleJ_83786]

You can never bill to the patient until Medicare makes it the patient responsibility. So you can bill to Medicare without the GA modifier first and if they deny then send a corrected claim with the GA modifier. This will then make Medicare change the status to the patient responsibility and then you can bill the patient.

 

[ManaleK_85648]

You can never bill to the patient until Medicare makes it the patient responsibility. So you can bill to Medicare without the GA modifier first and if they deny then send a corrected claim with the GA modifier. This will then make Medicare change the status to the patient responsibility and then you can bill the patient.

thanks for the reply. That helps a lot.

 

[ManaleK_85648]

This is from the Pub 100-04 Medicare claims processing Manual. How I understand it with the GA modifier is that the provider and patient understand that it will be denied as non-covered because it's not reasonable or necessary but that you have an ABN on file. The ABN must be on file signed by the patient prior to the services being billed to Medicare. The patient must know the exact amount of the cost and this should be reflected on the ABN.

The GA modifier must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary. (See http://www.cms.hhs.gov/medlearn/refabn.asp for additional information on use of the GA modifier and ABNs.)

I was not able to open the link. Got an error message. Thanks.