Submit claims for ONLY statutorily excluded services to Regence. Providers should submit only those services that are statutorily excluded by Medicare (e.g., home infusion therapy and hearing aids) to their local Blue Plan, Regence. (Note: For Medicare Crossover claims that do not include statutorily excluded services, you must wait 30 days to submit claims to Regence.)

Claims for the service that is excluded or not covered by Medicare should be submitted with Modifier -GY on each line:

  • Modifier -GY should be used to indicate that the item or service is statutorily excluded. This will allow Regence to apply the contracted rate with the provider to accurately process the claim according to the member's benefits.
  • By submitting statutorily excluded services with a Modifier -GY directly to Regence, you will receive payment for these services in a more timely manner.

This modifier should be used with the specific, appropriate HCPCS code when one is available. In cases where there is no specific procedure code to describe services, a "not otherwise classified code" (NOC) must be used with Modifier -GY.

Modifier -GY is located in the line level procedure code modifier field(s) and the modifier can be:

  • Present position 1, 2, 3 or 4.
  • On the 837P Modifier -GY is found at level 2400, Service Line Loop in SV101-3, SV101-4, SV101-5 or SV101-6.
  • On the 837I Modifier -GY is found at level 2400, Service Line Loop in SV202-3, SV202-4, SV202-5 or SV202-6.

Claims for statutorily excluded services submitted to Medicare will be returned. When a provider submits a claim to Medicare for services that are statutorily excluded and not covered by Medicare (however, the member has benefits for those services), the claim will crossover to the member's Blue Plan. The member's Blue Plan will deny the statutorily excluded services and indicate that the provider needs to submit those services directly to their local Blue Plan, Regence.

Instructions will be included in an electronic remittance advice (ERA) or letter from the Blue Plan.

ERAs (835)

The following HIPAA claim adjustment reason codes and remark codes will be included on the 835 responses:

  • Claim Adjustment Reason Code (CARC) 109: "Claim not covered by this payor/contractor."
  • Remittance Advice Remark Code (RARC) N837: "Alert: submit this claim to the patient's other insurer for potential payment of supplemental benefits. We did not forward the claim information."
  • Group Code: OA

Letters

When receiving a letter, you will receive instructions similar to the message below:

This service is excluded or not covered under Medicare. However, the service may be eligible for benefits under other coverage. Please submit this service to your local Plan.