BlueCross and BlueShield of Montana Medical Policy
Medical Policy

Advance Member Notification - Professional Services

 

Chapter: Administrative

© Blue Cross and Blue Shield of Montana

 

Current Effective Date: 01/02/2008
Original Effective Date: 01/02/2008
Revised Dates: [RevisedDates]

 

DESCRIPTION

Advance Member Notification (AMN) refers to the process in which a provider informs a member that a service, supply, device, or drug (hereafter, a service) is not likely to be considered for compensation by BCBSMT prior to the service being performed.

 

Through the AMN process, the member is able to understand the financial implications of receiving the service, and the participating provider is able to alter the financial liability of a service that would be denied as not medically necessary. The AMN process only applies to professional services. This policy does not apply to hospital-based services, skilled nursing facilities, or home health services.

POLICY

Advanced Member Notification For Experimental/Investigational Services and Other Contract Exclusions

BCBSMT member contracts contain language that does not allow compensation for services that are designated as experimental or investigational. These services are described in the medical policy Experimental/Investigational Services, Supplies, Drugs and Devices - Non-Covered.

BCBSMT encourages providers to have members sign an AMN for services BCBSMT may consider experimental/investigational so that the member is aware of their financial obligation to the provider prior to delivery of the service(s). Although securing an AMN is recommended prior to providing a service, a provider can balance bill a member for the following services:

• Services BCBSMT denies as investigational/experimental.

• Specific group or member contract exclusions (for specific contract exclusions, call the BCBSMT Customer Service Department at 1-800-447-7828).

• When a member is expected to need continued services beyond a specific maximum dollar contract benefit (for specific contract information, call the BCBSMT Customer Service Department at 1-800-447-7828).


If you are uncertain if a service will be denied as experimental/investigational, check the Codes Requiring Special Processing list at www.bluecrossmontana.com under
Provider then Prior Authorization. Or, call the BCBSMT Customer Service Department at 1-800-447-7828.

To prior authorize, fax your request to the Medical Review Department at 406-437-7863 using the Prior
Authorization form also found at www.bluecrossmontana.com under Provider then Prior Authorization. Or call the BCBSMT Customer Service Department at 1-800-447-7828. A retrospective review is performed, if services are not prior authorized.

Advanced Member Notification For Services Likely To Be Denied As Not Medically Necessary

BCBSMT member contracts contain language that does not allow compensation for services that are designated as not medically necessary. These services are described in the medical policy Medically Necessary Services. When a service is denied as not medically necessary, a participating provider may not balance bill the member, unless an AMN has been obtained prior to providing the service. If an AMN is on file, a participating provider can bill the member for services denied as not medically necessary.


A participating provider can also bill the member when a component of a service or item is in excess of the member's medical needs such as deluxe or upgraded items. Prior authorization is recommended for upgraded or deluxe durable medical equipment and/or prosthetics.


If you are uncertain if a service will be denied as not medically necessary, check the Codes Requiring Special Processing list at www.bluecrossmontana.com under
Provider then Prior Authorization. Or, call the BCBSMT Customer Service Department at 1-800-447-7828.

To prior authorize, fax your request to the Medical Review Department at 406-437-7863 using the Prior Authorization form found at www.bluecrossmontana.com under
Provider then Prior Authorization. Or call the BCBSMT Customer Service Department at 1-800-447-7828. A retrospective review is performed, if services are not prior authorized.

Content of a Valid Advanced Member Notification

A valid AMN must:

• Separately identify the proposed service(s) the provider believes will be denied by BCBSMT.

• Contain language that is understandable to the member or the member's authorized representative.

• Be presented far enough in advance of the service(s) so that the member or the member's authorized representative can make a rational, informed decision without undue pressure.

• Be signed by the member or member's authorized representative

• Provide an estimate of the cost for the denied service(s).


When Advance Member Notification May Not Be Used

An AMN may not be obtained:

• In a medical emergency situation.

• When the member or the member's authorized representative is under duress.

• By a provider, practitioner or supplier not providing the service(s) except if billing for laboratory tests.

• When used by a participating provider to balance bill the difference between the amount charged for a service and the BCBSMT allowable fee.

• For substitution of a dissimilar item or service (For example, if the provider orders a walker and the member wants to purchase a wheelchair. In this instance, BCBSMT will not pay for the wheelchair or apply the allowance for the walker toward the wheelchair).

• For hospital facility services, skilled nursing facilities or home health.

• When the provider anticipates one of the following types of denial:

• Bundled services (inclusive)

• Assistant surgeon not allowed

• No additional payment for applying a modifier

• Office visits related to a surgery within the pre- or post-op surgical period

For members who are insured through the Federal Employee Program or patients incarcerated by the Department of Corrections.

Examples of Advance Member Notice forms are available on the BCBSMT website (providers, then click on forms).

Coding

CPT only © American Medical Association. All Rights Reserved.

Claims billed with Modifier GA indicate a signed AMN is on file at the provider’s office. When the claim is processed, BCBSMT assigns financial liability to the member.


To submit a claim for an SSDD considered not medically necessary, experimental/investigational, cosmetic, or a convenience item, list the CPT code with the Modifier GA for each SSDD.

Charge

Allowance

Paid

Copayment, Co-insurance, or Deductible

Responsibility

91035-GA

$820.00

$753.87

$0.00

NA

The charge is member responsibility.


To submit a claim for deluxe medical equipment, list the HCPCS code on line one with the charge for the standard equipment. List the same HCPCS code with Modifier GA on line two with the charge for the upgrade or deluxe feature.

 

 

Charge

Allowance

Paid

Copayment, Co-insurance, or Deductible

Responsibility

Line 1 E0730-NU

$400.00

$370.56

$222.34

$144.22

The difference between the allowed amount and charge is the provider’s responsibility, except for copayment, co-insurance, or deductible.

Line 2 E0730-GA

$200.00

$200.00

$0.00

NA

The charge is member responsibility



BCBSMT considers submission of Modifier GA with a valid CPT or HCPCS code proof that the member has signed an AMN according to this policy and that the provider has the AMN on file.“


Unless BCBSMT requests a copy of the AMN, do not send an AMN with the claim.


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History of Development

[History]

 
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Advance Member Notification - Professional Services Advance Member Notification - Professional Services