Hospice services request for certification (Precertification and coverage criteria)
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Forms and requirements for precertification of hospice services for members of Blue Cross Blue Shield - Minnesota; governs provider submission of hospice certification and supporting clinical information.
No material clinical or coverage changes in this revision.
Coverage Criteria for Hospice Services
Initial hospice certification criteria
Covered when clinical documentation demonstrates advanced disease, intent for comfort-focused care, and required precertification is obtained.
From chunks 0,7,8
Providers should attach clinical notes, recent labs, and vital signs to support selected indicators (see form checklist)
From chunk 6
Failure to thrive and generalized weakness are explicitly identified as ineligible primary diagnoses for hospice benefit coverage and should not be submitted as the sole primary hospice diagnosis for certification.
Continuous Care is not a covered benefit and should not be requested on the hospice certification form.
The policy explicitly states that failure to thrive and generalized weakness are not acceptable primary diagnoses for benefit coverage; providers must document a medically supported, disease-specific hospice diagnosis with accompanying clinical indicators rather than using these nonspecific terms.
Clinical Indicators and Coding Thresholds
Provider Submission Requirements & Actions
Precertification required
Precertification for hospice services is required prior to or within 5 days of start of care. Submit the physician order for hospice with the request for certification. Fax completed form to 1-833-719-1609; for inquiries call 1-833-749-1967.
- Precertification required prior to or within 5 days of start of care
- Include physician order for Hospice with request for certification
- Fax completed form to: 1-833-719-1609; For inquiries: 1-833-749-1967
Service selection and equipment
Indicate place of care and all services provided. Identify durable medical equipment and supplies needed.
- Place of care: Home Care, Inpatient Hospice, Respite (Inpatient or Home)
- Services provided — indicate all and frequency: RN (SN), MSW, Home Health Aide (HHA), Chaplain, Therapist, MD/CRNP
- DME/supplies — list items such as hospital bed, bedside commode, oxygen/supplies, BiPAP, wheelchair, walker/cane, nutritional supplements, IV fluids, wound care, and other specified items
Required submission contents
Providers must submit complete patient demographic and clinical information and supporting documentation with the certification request.
- Patient information: name, address, telephone, DOB, contract holder, contract number, secondary insurance, primary caregiver and phone
- Primary hospice diagnosis with ICD-10 code and any secondary diagnoses
- Start of hospice date
- History and progression of disease (attach clinical notes) including worsening symptoms, functional decline, weight loss, recent ED visits/admissions
- Disease-specific clinical information (use checklist for heart, pulmonary, dementia/neurologic, HIV, liver, renal, ALS, etc.) and relevant objective data (NYHA class, Karnofsky score, O2 sats, lab values like albumin, INR, Cr clearance)
- Vital signs, recent laboratory data and dates (BUN/Cr, albumin), and Karnofsky score
- Medications (name, dosage, indicate if covered by hospice)
- Advance care details: patient desire for comfort-only care (Yes/No), DNR status (Yes/No)
- Prior hospice or home health in last 6 months (include agency name and phone if yes)
- Ordering MD information (not Hospice Medical Director): name, NPI, office address — and note: submit physician order for Hospice with request for certification
- Hospice identification: hospice name, address, provider NPI, telephone, fax, tax ID, name of Hospice Medical Director, and any additional information
Ineligible primary diagnoses
The following primary diagnoses are not eligible for hospice benefit coverage and should not be submitted as the primary hospice diagnosis.
- Failure to thrive
- Generalized weakness
Background
This form gathers clinical indicators used to support hospice eligibility, including advanced disease stage, functional decline (for example, Karnofsky < 40), oxygen requirements, weight loss, laboratory abnormalities (such as albumin < 2.0, creatinine clearance < 10 ml/min, or serum creatinine > 6.0 where applicable), and documentation that the patient desires comfort-focused care with DNR status as appropriate. Providers must submit a disease-specific primary hospice diagnosis with supporting clinical notes and labs rather than nonspecific diagnoses like failure to thrive or generalized weakness.
Definitions and Form Options
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