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 Reopening Rights
GA

Beneficiary: Yes.

Provider: Yes.

  • Line-item will deny as beneficiary-liable
  • May request to remove GA modifier
  • May request to add GA modifier. Request must include copy of valid ABN
  • Note: In certain situations, a line-item may deny as provider-liable. Example includes, but is not limited to, Preventive service which does not meet medical necessity (as driven by diagnosis code) and is not subject to frequency edits

Provider:

  • May request to remove GA modifier
  • May not request to add GA modifier
GX

Beneficiary: Yes.

Provider: Yes.

  • May request to remove GX modifier
  • May request to add GX modifier

Provider:

  • May request to remove GX modifier
  • May not request to add GX modifier
GY

Beneficiary: Yes.

Provider: Yes.

  • Line-item will deny as beneficiary-liable
  • May request to remove GY modifier
  • May request to add GY modifier

Provider:

  • May request to remove GY modifier
  • May not request to add GY modifier
GZ

Beneficiary: Yes.

  • This may increase beneficiary's cost-sharing responsibility

Provider: Yes.

  • Line-item will deny provider-liable; request appeal
  • May request to add GZ modifier
  • May request to remove of GZ modifier

Provider:

  • May request to add or remove GZ modifier; no documentation is required

 

Last Updated Fri, 12 Jul 2019 09:34:13 +0000