Modifier Code GA

Modifier code GA is used to indicate that the patient knows that the services do not meet the plan's guidelines for coverage, has indicated that he or she wants the services performed despite noncoverage, and has signed a waiver indicating that he or she will be personally responsible for the denied charges.

The intent of the modifier is to alert the health plan that the claim should be processed to indicate that the Member owes for the service, and that the noncovered charges not be made a provider adjustment.

HMSA expects that this modifier would be used in only a few specific cases. These exceptional cases are as follows:

• Anesthesia for a patient who is not at risk, but prefers to receive anesthesia performed by an anesthesiologist rather than conscious sedation administered by the attending physician or the physician's staff. See Anesthesia Procedures - Claim Documentation Requirements, Anesthesia Services for Gastrointestinal Endoscopic Procedures.
• Genetic testing that does not meet HMSA's criteria for coverage and for which precertification has been denied. See Genetic Testing for Hereditary Breast and/or Ovarian Cancer, Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes, Genetic Testing for Non-Cancerous Inheritable Diseases, Genetic Testing of Inherited Cancer Predisposition.
• Bone (Mineral) Density Studies
• Digital Breast Tomosynthesis
• Completely in the Canal (CIC) Hearing Aids
• Gender Identity Services

Services That Do Not Meet HMSA's Payment Determination Criteria

Select services are considered noncovered services. Claims submitted for these services will be denied and the provider must not bill or collect charges for these services from the member unless a written acknowledgement of financial responsibility, specific to the service, is obtained from the member prior to the time services are rendered. Effective January 1, 2008, modifier code GA should be appended when billing for the services listed in the following table.

• Codes That Do Not Meet Payment Determination Criteria

Documentation

A copy of the signed waiver must be kept in the patient's medical record.

HMSA reserves the right to audit claims using modifier GA and may ask to review medical records for proper documentation.

HMSA Akamai Advantage® Plans

The GA modifier is also recognized by HMSA Akamai Advantage plans. However, providers should follow the HMSA Akamai Advantage correct billing instructions for this modifier; refer to Correct Billing Instructions for Modifiers GA, GX, GY and GZ.

Revision History