Last Modified: 6/22/2019
Location: FL, PR, USVI
Business: Part A, Part B
If a provider or supplier expects that the service or item furnished to the beneficiary may be considered unreasonable and/or medically unnecessary by Medicare, an advanced beneficiary notice (ABN) may be used to inform the beneficiary of his or her financial liability, appeal rights, and protections under the fee-for-service (FFS) Medicare program.
Providers and suppliers should use the appropriate modifier when submitting such claims to indicate whether they have or do not have an ABN signed by the beneficiary.
• Modifier GZ -- must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary, and they do not have an ABN signed by the beneficiary.
Effective July 1, 2011, all claims line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review. For additional information, please refer to the MLNŽ Matters article MM7228
• Modifier GA -- 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 an ABN signed by the beneficiary on file.
Note: All claims not meeting medical necessity of a local coverage determination (LCD) must append the billed service with modifier GA or modifier GZ.
For more information concerning ABNs and other types of notices, please refer to the Centers for Medicare & Medicaid Services’ (CMS) Beneficiary Notices Initiative
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