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Member-Demanded Services for Migrated Members

Blue Cross Blue Shield of North Dakota (BCBSND) has allowed the use of the GA modifier related to professional services only. As we transition to our new system, it will recognize and process professional and institutional claims for migrated members only, with the GA modifier, 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.

Services submitted with the GA modifier 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.

The AMN forms provided by BCBSND must be completed, verbally reviewed with the member or their representative, and signed by the member before the service is provided. The AMN acknowledges that the member is fully responsible for all charges associated with a procedure/item/service requested because the procedure/item/service may not be medically necessary and/or is not a covered benefit. A copy of the signed AMN should be given to the member and the original kept on file. The signed AMN is subject to audit by BCBSND.

BCBSND has developed a new AMN form for migrated members receiving services after their migration date. Both migrated and non-migrated member forms will be available at www.bcbsnd.com/web/providers/forms. Please make sure to use the appropriate form. AMNs for institutional services will not be accepted for non-migrated members. Do not use Medicare’s form or other provider-designed waiver forms. The AMN must specifically identify the non-covered services and procedure codes. General notices will not be accepted.

With the exception of benefit reasons, AMNs cannot be used to collect amounts otherwise not payable, including:

  • Medical policy
  • 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 the Federal Employee Program (FEP).