Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health Management
Overview (continued) When submitting claims, indicate with a –GA in box 24D modifier
those services that have a valid signed statement on file.
We do not consider blanket (nonspecific) waivers sufficient
notice to meet the patient notification requirements in your
provider services agreement. The waiver must be dated and
must specifically identify the procedure or service. The waiver
must also advise the patient that he or she would not be liable
for these charges unless the waiver is signed.
GA Modifier Use the -GA modifier in field 24D of the CMS-1500 form to
indicate:
you have notified a patient that a specific service has been
determined by Blue Cross to be investigative or not medically
necessary, and
those services will most likely not be covered under the
member’s contract.
After this notice, and prior to receiving the services, the patient
must have agreed in writing that charges incurred will be the
patient’s liability.
The use of this modifier will result in allowed amounts related to
these services being reported in the patient responsibility column
of your provider remittance.
Note: The -GA modifier should not be used routinely on all of
your claims submittals. Inappropriate use of the -GA
modifier may result in an audit of your files and possible
payment adjustments.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-33