Liability Modifier Appeal Rights

The below provides clarification on the appeal rights (by party to an appeal) for the following:

  • Claim has been submitted and processed with a liability modifier(s) but appellant wishes to remove it/them
  • Claim has been submitted and processed without a liability modifier(s) and appellant wishes to add it/them, if applicable

Although Reopenings is not an appeal level, it does offer suppliers the option to request clerical adjustments to their claims.

Modifier Appeal Rights
GA Beneficiary: Yes.

Supplier: Yes.
  • Neither removal nor addition of GA modifier can be done through Reopening process
  • Suppliers may submit a Redetermination request to remove or add GA modifier
    • If adding GA modifier, suppliers must submit a valid ABN along with supporting medical documentation
GX Beneficiary: Yes.

Supplier: Yes.
  • Neither removal nor addition of GX modifier can be done through Reopening process
  • Line-item will deny as beneficiary-liable.
  • Suppliers may submit a Redetermination request to remove or add GX modifier
    • If adding GX modifier, suppliers must submit a valid voluntary ABN along with supporting medical documentation
GY Beneficiary: Yes.

Supplier: Yes.
  • Neither removal nor addition of GY modifier can be done through Reopening process
  • Suppliers may submit a Redetermination request to remove or add GY modifier
    • If adding it, suppliers may submit a valid voluntary ABN, if applicable (not required), along with supporting medical documentation
GZ Beneficiary: Yes; however, this may increase the beneficiary's cost-sharing responsibility.

Supplier: Yes.
  • Line-item will deny provider-liable and must be appealed. Neither removal nor addition of GZ modifier can be done through Reopening process
  • Suppliers may submit a Redetermination request to remove or add GZ modifier
    • If adding GZ modifier, suppliers must submit supporting medical documentation

 

Last Updated Aug 30, 2018