Hospice services medical necessity
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Defines medical necessity criteria, required documentation, levels/intensity of hospice care, and exclusions for hospice benefits for members of Arizona Complete Health (Centene-associated plans). Applies to providers requesting hospice authorization.
No material clinical or coverage changes in this revision.
Hospice Coverage Criteria
inv-01: Initial Request
Covered when ALL of the following are met
Only one level of care may be authorized per day.
inv-02: Disease-specific severity criteria
Disease-specific severity criteria (examples — not exhaustive in this window)
Consider presence of significant comorbidities when applying these criteria.
inv-03: Intensity of Service (Levels of Care)
Level of care is appropriate when ALL listed conditions per level are met
Bill HCPCS T2042 or rev code 0651 as applicable.
At least 50% of total care must be provided by a nurse; bill HCPCS T2043 or rev code 0652.
Bill HCPCS T2044 or rev code 0655.
Bill HCPCS T2045 or rev code 0656.
inv-04: Subsequent Requests and Recertification
Subsequent requests are medically necessary when meeting listed conditions
Certification/benefit periods: initial 90‑day, second 90‑day, then unlimited 60‑day periods.
Authorization is required for each change in level of service and only one level may be authorized per day.
inv-05: Covered hospice services
Covered when ALL of the following are met as part of the hospice treatment plan
Includes physician services; skilled nursing; home health aide; physical, occupational and speech therapy; medical social services; counseling (including bereavement); short‑term inpatient care; prescription drugs necessary for palliation and management of the terminal illness and related conditions; and consumable medical supplies related to hospice care.
inv-06: Continuous hospice home care
Continuous hospice home care coverage criteria
Not intended as respite care or an alternative to paid caregivers or placement. Continuous care may include services listed under covered services.
inv-07: Inpatient levels of care
Inpatient respite and general inpatient coverage
A primary caregiver is an individual designated by the member who is responsible for 24‑hour care; caregiver is not required to elect hospice if member is safe at home at time of election.
The policy explicitly excludes members whose primary diagnosis is debility or failure to thrive from hospice coverage. When either of these is listed as the primary diagnosis, hospice services are considered not medically necessary. This exclusion also applies to unspecified debility. Providers should therefore confirm and document the primary diagnosis carefully; if debility or failure to thrive is documented as primary, hospice authorization is not indicated under this policy.
Hospice services are not covered when furnished during an acute inpatient stay for a diagnosis unrelated to the terminal illness. Additionally, services are not covered for individuals who are no longer considered terminally ill. Providers must ensure that inpatient acute care for unrelated conditions is billed and authorized through the appropriate benefit rather than as part of the hospice treatment plan.
Coverage under this hospice policy is subject to the terms, conditions, exclusions and limitations in the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy or contract), as well as applicable state and federal requirements and Health Plan administrative policies. Where state Medicaid provisions conflict with this policy, state provisions take precedence. Providers must follow the member's benefit document and applicable legal/regulatory requirements when requesting authorization and submitting claims.
The policy identifies specific scenarios that render hospice services not medically necessary. Key among these is when the primary diagnosis is debility or failure to thrive. Other not medically necessary circumstances include when the member is no longer considered terminally ill based on medical documentation, when services are directed toward curing the terminal condition (with the exception of concurrent care for children on Medicaid/CHIP), when the member revokes the hospice election in writing, or when the member is discharged from hospice for reasons such as refusal of services, relocation, or transfer to a non-covered hospice program.
Hospice coverage terminates when the member is no longer considered terminally ill; in such cases, services under the hospice treatment plan are not covered. The policy requires that medical documentation support continued terminal prognosis; absent that documentation, hospice eligibility should be discontinued and care transitioned to the appropriate benefit. Providers should notify the health plan of changes in status (including discharge) and obtain authorization for any subsequent or alternative services.
Codes, Billing Thresholds, and Key Metrics
| T2042 | Routine Hospice Home Care |
| T2043 | Continuous Hospice Home Care |
| T2044 | Inpatient Respite Hospice Care |
| T2045 | General Inpatient, Short Term Hospice Care |
| 0651 | rev code for Routine Hospice Home Care |
| 0652 | rev code for Continuous Hospice Home Care |
| 0655 | rev code for Inpatient Respite Hospice Care |
| 0656 | rev code for General Inpatient Short Term Hospice Care |
| T2042 | Hospice routine home care; per diem |
| T2043 | Hospice continuous home care; per hour |
| T2044 | Hospice inpatient respite care, per diem |
| T2045 | Hospice general inpatient care; per diem |
| T2046 | Hospice long-term care, room and board only; per diem |
| G0337 | Hospice evaluation and counseling services, pre-election |
| 0651 | Hospice routine home care; per diem |
| 0652 | Hospice continuous home care, per 15 minutes |
| 0655 | Hospice inpatient respite care, per diem |
| 0656 | Hospice general inpatient, non-respite care, per diem |
| 0658 | Hospice room and board, nursing facility |
| 0657 | Hospice charges for services furnished to patients by physician or nurse practitioner employees |
| GV (modifier) | Physician services performed by a nurse practitioner require GV modifier with revenue code 0657 |
Authorization, Documentation, and Provider Responsibilities
Coverage Document Compliance
Providers must follow the terms, conditions, exclusions and limitations of the member's coverage document (e.g., evidence of coverage, certificate of coverage, policy or contract). When state Medicaid provisions conflict with this clinical policy, state Medicaid rules prevail. For Medicare members, review applicable National and Local Coverage Determinations (NCDs/LCDs) and Medicare Coverage Articles prior to applying policy criteria. The health plan may change, amend, or withdraw this clinical policy; provider billing and service delivery remain subject to applicable legal, regulatory, and Health Plan administrative requirements.
- Coverage document terms govern benefit administration; state Medicaid provisions supersede when in conflict
- For Medicare members, verify applicable NCDs/LCDs and Medicare Coverage Articles before applying criteria
Provider Documentation and Notifications
Verify member/enrollee eligibility and obtain authorization from the Health Plan before initiating hospice services. Notify the Health Plan promptly of significant changes in the member/enrollee's status or condition (including changes to treatment plans, goals, level of care, or discharge). Request authorization for each change in level of hospice service (only one level of care may be authorized per day). Maintain and submit updated hospice medical director certifications for initial and subsequent 90-day certification periods as applicable.
- Obtain authorization prior to initiating hospice care; failure to obtain authorization may risk denial
- Request authorization for each change in level of care and for discharge
- Submit hospice medical director written certification for initial 90-day and subsequent recertification periods
Documentation & Claims Compliance
Ensure clinical documentation supports medical necessity and claims. Maintain written hospice medical director certification identifying the terminal diagnosis and a statement that life expectancy is six months or less if the terminal diagnosis runs its normal course, plus supporting clinical findings. Include a signed hospice election statement from the member/enrollee or healthcare proxy. Bill the appropriate HCPCS or revenue codes corresponding to the authorized level of care and follow applicable contract billing provisions and state/federal claim submission rules.
- Written medical director certification with clinical findings and terminal diagnosis required for initial 90-day certification
- Signed hospice election statement required
- Bill correct HCPCS (T2042–T2045) or revenue codes (0651–0656) for the authorized level of care
- Authorization required for each change in level of care; only one level authorized per day
Definitions and Levels of Care
Policy Background and Scope
Hospice provides multidisciplinary, palliative-focused care for members with a limited life expectancy. This policy applies hospice benefits when the member's life expectancy is six months or less if the terminal illness runs its normal course, and emphasizes symptom relief and support rather than curative treatment. Care is delivered across disciplines (physician direction, skilled nursing, aides, therapies, social services, counseling and short-term inpatient services) with authorization and documentation required to establish medical necessity and the appropriate level of care.
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