Guidelines for using Advance Notice of Member Responsibility form

Modifiers GY or GZ are not required for every claim. If you bill for professional services using the GY or GZ modifier, Blue Cross Blue Shield of Michigan requires providers to complete the Advance Notice of Member Responsibility form. Once the form is complete, providers are then required to report the GA modifier. Modifier GA acknowledges that the member has signed the form prior to any services rendered and has agreed to accept financial responsibility for the service. The form and the modifiers work together in this new policy. If the modifiers GY or GZ are not billed, the form is not required.