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Modifier GJ


GJ Opt-out physician/practitioner EMERGENCY OR URGENT SERVICES

In an emergency or urgent care situation, a provider may treat a Medicare beneficiary with whom he or she does not have a private contract and bill Medicare for such treatment. The provider may not charge the beneficiary more than the limiting charge and must submit a claim to Medicare on the beneficiary's behalf. Medicare payment will be made to the beneficiary for covered services in this situation if the claim is unassigned. In order to submit an assigned claim and be paid directly by Medicare for such services, the opt out provider would need to complete a CMS-855 enrollment form to apply for enrollment in the Medicare program. (This would not affect the provider's opt out status for purposes of other services.)

Opt out providers use Modifier GJ with the procedure code to identify services that were emergency or urgent when there was no private contract in effect with the beneficiary at the time the services were performed.

This modifier must be used on claims for services rendered by an opt-out physician/ practitioner for an emergency/urgent service.

If the physician or practitioner did not submit GJ national HCPCS modifier, then the carrier would deny the claim so that the beneficiary can appeal.

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