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 providers the option to request clerical adjustments to their claims.

Modifier Appeal Rights
GA Beneficiary: Yes.

Provider: Yes.
  • If claim line was submitted and processed as covered, line can be adjusted (including modifier removal)
  • If line denied (denies beneficiary-liable), request an appeal
  • Note: In certain situations, line-item may deny as provider-liable. An example includes, but is not limited to, a preventive service which does not meet medical necessity (as driven by diagnosis code) and is not subject to frequency edits
GX Beneficiary: Yes.

Provider: Yes.
  • Line-item denied as beneficiary-liable, request an appeal
  • Note: Append this modifier to report that a voluntary ABN was issued for a service. Lines submitted as non-covered will deny as beneficiary-liable
GY Beneficiary: Yes.

Provider: Yes.
  • May adjust claim to remove modifier and re-submit as covered. Noridian may review for medical necessity
GZ Beneficiary: Yes.

Provider: Yes.
  • Line-item denied provider-liable, request appeal
  • Note: May only request to remove this modifier during redetermination process. Medical records will not be reviewed to determine medical necessity

 

Last Updated Aug 20, 2018