Reminder: Advance Member Notice (AMN)
Network providers shall notify members when a requested service is not medically necessary or is noncovered (e.g., contract exclusion, not a covered benefit). A member must be informed in advance with an Advanced Member Notice (AMN) indicating service description and associated costs. If the member chooses to be financially responsible for the noncovered service, the member shall sign the AMN agreeing to pay for the service.
The use of the GA modifier is allowed on professional and institutional claims, as indicated below:
- GA modifier: Member has requested a non-covered service and has signed an Advance Member Notice form (AMN, also known as a “waiver”), agreeing to pay for the service. The requested service is not medically necessary for their condition. Charges will be denied, as member liable.
Medical information will not be requested or reviewed prior to the denial. BCBSND will conduct routine audits of services billed with these modifiers, requesting chart notes (and signed AMNs, if applicable) to verify appropriate usage. Services billed inappropriately will be reprocessed as provider liable. Further actions may be taken if inappropriate usage continues.
Except for benefit reasons, AMNs cannot be used to collect amounts otherwise not payable, including:
- Medical policy:
- The AMN is to be used when services are not medically necessary.
- The AMN is not necessary for a Medical Policy that indicates the procedure or service is cosmetic or experimental/investigative in nature as claims will continue to deny as member liable.
- Providers on Corrective Action Plans.
- Services provided outside the scope of the provider’s license.
- High charges for covered services.
- Bundled services.
- Items included in a procedure (e.g., surgical trays)
- Multiple procedure discounts AMNs cannot be used to collect from members for failure to obtain precertification.
- AMNs cannot be required as a condition of providing covered services.
This does not apply to FEP.
Providers can find additional information in our provider manuals and also a fillable Advance Member Notice Form located on our Provider website, or use a form of their own. An Advanced Beneficiary Notice (ABN) can only be used for traditional Medicare Part A & B services and is not accepted as an AMN.