Blue Cross Idaho (Medicare Advantage) Announces Requirement for Modifier CG use with Organizational Determinations

If you provide services to Medicare Advantage Plan (MA) patients that might not be covered by the MA Plan, this is an important notice.

We recently learned of a notification from Blue Cross Idaho for their MA plans requiring the use of a very unusual modifier in certain situations.  In the February 9, 2016 PROVIDER ALERT that affects all providers, the insurer made the following points for their MA plans:

  • An organizational determination is to be obtained in advance and in place of the ABN process to notify beneficiaries of possible financial responsibility for services.
  • The “standard” Advance Beneficiary Notice of Noncoverage (ABN) for Medicare is not allowed to be used for MA plans.
  • “ABN modifiers” GA and GY can no longer be used as part of the claims process when an organizational determination is in place.
  • Healthcare Procedure Coding System (HCPCS) modifier CG is now required on all claims where the organizational determination was obtained. It’s used to ensure proper assignment of responsibility for these services, and to prevent the plan from designating the denied services as provider liability (instead of patient liability).
  • The requirement to use modifier CG was enforced as of March 1, 2016.

Importantly, Medicare has made it clear to all MA plans that providers who fail to obtain an organizational determination may not make the patient responsible for payment of the (noncovered) denied services – even if the patient agreed and paid you already.

Modifier CG has a short and highly unusual definition, but it is acceptable for them to require it.  The full HCPCS modifier descriptor is “Policy criteria applied”.

In a previous news item on our website we provided additional information on a letter sent from CMS to the MA plans noting the rationale and regulatory basis for the unsuitability of the ABN form, and the need for an organizational determination when services you deliver are potentially noncovered and an MA plan is in place for that beneficiary.  You can link here to that news item from 2014.

Your best defense to protect your practice’s “noncovered” services revenue is to be aware of and adhere to each payer’s requirements – they may vary significantly.

If you need assistance, Corcoran Consulting Group can help.  You can also get and use our new App, Corcoran 24/7 via one of the links below –it’s free. (800) 399-6565

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