“Demand” or “No pay” Claims Processing for the Medicare MNT Benefit

“Demand” or “No pay” Claims Processing for the Medicare MNT Benefit

There may be instances when the Medicare beneficiary has a secondary insurance in addition to Medicare, and a determination that Medicare will not pay for the services is required before the secondary insurer will process the claim. This determination process is call a "no pay" or "demand bill"1. Do not confuse this claims processing activity with the ABN requirement for Medicare services. The secondary insurer demand bill requirement is about claims submission. Because providers need to submit a claim in order to get a Medicare denial, this does not mean an ABN should be used. Remember, for all services for which Medicare does not pay at all, beneficiaries and providers including RDs can privately work out payment agreements, without any Medicare involvement. In this case, no ABNs are required. What needs to be done involves filling out and submitting a HCFA 1500 form.

When submitting the CMS1500 claims form, providers should use specific coding language for statutorily non-covered services. These codes are used specifically for denying claims as required by some in order to bill other insurance. (see codes information listed below). For "demand" and "no pay" claims, the RD does not need to be a Medicare provider and does not need to list a Medicare provider identification number on the CMS1500 form. The RD's social security number may be used in these instances.

"Demand Bill" Codes for CMS1500 Form
RDs may need to use the following modifiers when submitting CMS1500 forms for MNT services for diabetes and non-dialysis kidney disease to the local Medicare carrier.

Modifiers2,3
GA — Used when a provider expects a denial and they have obtained a waiver or ABN from the patient. Listed on line 24d on the CMS1500 form.

GY — Used when a service is statutorily excluded (e.g. preventive exams or MNT for other diagnosis besides diabetes or non-dialysis kidney disease) or does not meet the definitions of any Medicare benefit. Listed on line 24d on the CMS1500 form. A waiver or ABN is not necessary.

GZ — used when a service is expected to be denied as not reasonable or necessary and you did not obtain a signed ABN from the patient. Listed on line 24d on the CMS1500 form.

Demand Bill Example:
A physician refers a Medicare patient with hyperlipidemia to an RD for MNT services in the RD's private practice. The RD is currently not a Medicare provider and does not have a Medicare provider identification number (PIN). Since Medicare only covers MNT services for diabetes and non-dialysis kidney disease, MNT for hyperlipidemia is a non-covered service and an Advanced Beneficiary Notice is not needed. Prior to receiving MNT, the RD informs the patient that Medicare will not pay for the service, and the patient is responsible for the payment. The patient requests the RD obtain a demand bill from Medicare, so that the claim can be sent to the patient's secondary insurance. The RD completes the CMS1500 form to submit to Medicare. Key items to complete include line 24d, the CPT procedure code and modifier, 97802-GY, this indicates that the MNT assessment and intervention service is statutorily non-covered by Medicare and an ABN was not provided to the patient. On line 25, the RD lists his/her federal tax identification number (in lieu of the Medicare PIN).

Practice Tips

  • Demand bills are used for claims processing and may or may not be used with Advanced Beneficiary Notices (ABNs). On the other hand, ABNs are used before services are provided to patients to indicate the patient's responsibility for payment when there is some uncertainty that Medicare will pay for the covered service. (For more information on ABNs, see "Advanced Beneficiary Notices (ABNs) for the Medicare MNT benefit" in the Medicare Provider Information section on ADA's Web page: www.eatright.com/members/provlinks.html.)
  • RDs need to remember to include their federal tax identification number, social security number or Medicare PIN, and the appropriate procedure code with modifier on the CMS1500 form.
  • Demand bills are sent to Medicare for payment denial documentation so the CMS1500 claim for the non-covered services can be submitted to secondary insurers for payment. Medicare will return an EOB (explanation of benefits) form indicating Medicare does not cover the service.
  • Currently, the "GY" modifier can and should be appended to the MNT CPT code when a non-covered service (for diagnosis other than diabetes or non-dialysis kidney disease) needs to be billed to Medicare for the secondary payer claims processing. (For example, while Medicare may not cover a particular service, the patient's secondary insurance might cover it. For the secondary insurer to review and possibly process the claim, the patient will need a demand bill, or denial from Medicare before the secondary payer will issue payment.)
  • When an RD files a secondary claim, always attach a copy of the primary claim's EOB to the claim form. To prevent violating confidentiality laws, RDs should take a black marker and mark out the patient's name on the EOB before filing the secondary claim. This may prevent a patient from filing a confidentiality lawsuit.

*The information is for reference use only and does not constitute the rendering of legal, financial, or other professional advice of the American Dietetic Association. (7/27/04)

1 CMS Program Memorandum Intermediaries, A-01-77, June 27, 2001. "Advance Beneficiary Notices (ABNs) for Services for Which Institutional Part B Claims Will be Processed by Fiscal Intermediaries" Accessed from: www.cms.hhs.gov/manuals/pm_trans/a0177.pdf

2Compliance Compass, Vo. 2. Issue 4; Sept/Oct 2001; www.mc.vanderbilt.edu/compliance/downloads/news09-01.pdf.

3CMS Program Memorandum, Transmital B0158, September 25, 2001; "Coding for Non-Covered Services and Services Not Reasonable and Necessary," www.cms.hhs.gov/manuals/pm_trans/b0158.pdf

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