Medical coding and billing are themselves complex tasks and become more complicated when the addition of modifiers such as the GA modifier further amplifies this complexity. The absence of this modifier in the bill can cause you to lose a large amount on your reimbursements, which you cannot even claim from the patient. In 2011, Medicare has paid around $744 million for the services that providers were considering as not covered by the payer. But just because they have added GA modifier according to the regulatory instructions so they were paid for their rendered services. This is how much important this GA modifier is.
In order to protect providers from losing the money they are due, the use of the GA modifier on submitted claims for patients with UnitedHealthcare commercial plans has been made required by providers. In this blog, we will explain everything you need to know about the GA modifier; what it means, how it works, the UnitedHealthcare commercial plans updates, and what healthcare providers can do to stay compliant.
What is the GA Modifier?
The GA modifier in medical billing is used to indicate that a waiver of liability statement or (ABN) an Advance Beneficiary Notice is on file. This modifier tells insurance providers, such as Medicare or commercial payers, that the patient has been notified in advance that a service or procedure may not be covered and that they agree to be financially responsible.
Simply put, the GA modifier means, “We told the patient this might not be covered, and they agreed to pay if needed or denied by the payer.” GA modifier for Medicare billing is commonly used but it can also apply to commercial insurance in certain situations.
GA Modifier Description
The GA modifier signals that an Advance Beneficiary Notice has been properly issued to the patient. For providers billing modifier GA Medicare or commercial payers, this documentation ensures that the patient knows ahead of time that a service might not be covered and that they will take responsibility for payment if the claim is denied.
How Does the GA Modifier Work?
When a healthcare provider thinks or feels that a service might not meet the payer’s coverage standards and might not be paid, they add the GA prefix to the claim. For example:
- The service could be considered medically unnecessary under GA modifier advantage Medicare guidelines.
- The payer may not cover the procedure for the specific condition.
- The treatment is an experimental service or outside usual care.
Before applying the GA modifier, the healthcare provider must issue an ABN to the patient. The ABN clearly explains:
- Which services may not be covered.
- Why the provider believes the services might not be reimbursed.
- That the patient agrees to pay for the service if it is denied.
When the GA modifier is added to the claim, it acts as proof that the provider informed the patient ahead of time, protecting the provider from financial liability disputes.
When a Medicare claim is made, the modifier helps make sure that the provider is following Medicare modifier GA rules. In the same way, for private insurance companies they can avoid late payments or reporting mistakes by using the GA modifier properly.
What Is the New GA Modifier Update for UnitedHealthcare Commercial Plans?
UnitedHealthcare has introduced a new update regarding the use of the GA modifier for commercial insurance plans. This update aligns UnitedHealthcare’s policies more closely with existing Medicare rules for modifier GA usage, adding clarity and ensuring accurate claims submission.
It has introduced a key update requiring healthcare providers to include the GA modifier when submitting claims for services that might not meet coverage criteria, provided a waiver of liability (similar to an ABN) has been signed by the patient.
This change emphasizes the importance of notifying patients in advance about services that might not be covered under their UnitedHealthcare commercial plans & obtaining their agreement to assume financial responsibility.
How and When Will This Update Be Implemented for UnitedHealthcare Commercial Plans?
The new 2025’s GA modifier update for UnitedHealthcare commercial plans is set to take effect on February, 1. This means that providers must start applying the GA modifier to applicable claims & ensure that proper documentation, such as a waiver of liability form, is maintained for compliance.
Here’s how this implementation is going to work:
- Eligibility Verification: Providers should verify coverage for services in advance & determine whether a service may be denied due to lack of medical necessity.
- Patient Notification: If there’s a chance that the service will not be covered, providers must inform the patient and have them sign a waiver agreeing to pay if the claim is denied.
- Submission of a Claim: When submitting the claim, providers must attach the GA modifier to flag the service and indicate that the patient was informed.
- Denial Management: If UnitedHealthcare denies the claim, that means patient becomes responsible for the payment, as per their prior agreement.
The update applies specifically to UnitedHealthcare’s commercial plans, so providers should familiarize themselves with the details of this requirement to avoid billing errors.
What Does This Update Require from Healthcare Providers?
To comply with the new UnitedHealthcare GA modifier update, healthcare providers need to:
- Issue Proper Waivers of Liability: Make sure the patient knows what services might not be covered and signs a waiver before the treatment or surgery.
- Add the GA Modifier to Claims: Apply the GA modifier correctly to claims for services that may not meet coverage requirements.
- Maintain Documentation: Keep a record of the signed waivers or liability forms for audit purposes.
- Train Staff: Educate billing and administrative teams about the new requirement to ensure proper implementation.
- Verify Coverage Policies: Check UnitedHealthcare’s commercials’ guidelines often to stay up to date on changes to coverage rules and how to use modifiers.
By following these steps, providers can make sure they are following UnitedHealthcare’s rules and avoid having claims denied or held up.
Why Is It Important to Follow This Update for Providers?
Following the new GA modifier update for UnitedHealthcare commercial plans is critical for healthcare providers for several reasons:
- Avoid Claim Denials: Incorrectly submitted claims without the GA modifier may be denied, delaying payment and increasing administrative work.
- Avoid No Payment Recovery: Failure to include the GA modifier when billing for such services means you cannot bill the member for the non-covered service.
- Ensure Financial Transparency: Informing patients in advance about potential non-coverage builds trust and ensures they are prepared for any out-of-pocket costs.
- Compliance with Insurance Policies: Staying compliant with UnitedHealthcare’s billing guidelines helps prevent errors, audits, and penalties.
- Improve Revenue Cycle Management: Proper use of the GA modifier streamlines the billing process, reducing the risk of lost revenue due to denied claims.
- Protect Provider-Patient Relationships: Transparency about financial responsibility helps maintain positive relationships with patients, reducing disputes over bills.
By adhering to these updated requirements, providers can ensure smoother claim submissions, improved reimbursement processes, and better communication with patients.
Where can I find more information on UnitedHealthcare’s GA modifier requirement? You can refer to the official UnitedHealthcare provider guidelines* or contact their support team for detailed information about this update.
Final Thoughts: Stay Ahead with GA Modifier Compliance
The GA modifier is an integral yet minor detail that makes a major impact in the medical billing process, while ensuring providers act within compliance and cover themselves from liability. With UnitedHealthcare’s new update for commercial plans, it’s imperative for providers to correctly append the GA modifier to ensure appropriate documentation. Providers can improve revenue cycle management by giving patients information about services that aren’t likely to be covered, collecting waivers, and upon submitting claims, utilizing the GA modifier.
Stay proactive, train your teams, and keep patient communication clear to ensure smooth transitions under this update. With the right approach, managing the GA modifier can become a seamless part of your billing process, benefiting both providers and patients.
Frequently Asked Questions (FAQ)
Do I put modifier GA on commercial insurance?
Typically, the GA modifier is specific to Medicare claims. For commercial insurance plans, providers should check the payer’s specific guidelines for non-covered services.
Can the GA modifier be used with other modifiers?
Yes, it can be combined with other modifiers as needed, but proper coding rules must be followed to avoid claim rejections.
Does this rule apply to all UnitedHealthcare plans?
No, this requirement applies only to commercial plans. It does not affect Medicare or other plan types where ABN-like processes are already in place.
