CurrentDHAPolicy 4.0

Concurrent Hospice and Curative Care for Pediatric Beneficiaries

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This policy governs coverage, preauthorization, and reimbursement of hospice services provided concurrently with medically necessary curative TRICARE Basic Program services for eligible beneficiaries under age 21 with a related terminal illness.

Policy Summary

PayerDHA

PolicyConcurrent Hospice and Curative Care for Pediatric Beneficiaries

Policy CodePolicy 4.0

Change TypeNo material change

Effective DateDec 12, 2017

Next Review DateN/A

Key ActionObtain preauthorization before providing concurrent hospice and curative care to a beneficiary under age 21.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Maximum beneficiary age for concurrent care

6 monthsRequired terminal illness life expectancy

PreauthorizationConcurrent care utilization requirement

3 daysInitial care-plan completion deadline

Every 15 days

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CurrentDHAPolicy 4.0

Concurrent Hospice and Curative Care for Pediatric Beneficiaries

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Policy Summary

PayerDHA

PolicyConcurrent Hospice and Curative Care for Pediatric Beneficiaries

Policy CodePolicy 4.0

Change TypeNo material change

Effective DateDec 12, 2017

Next Review DateN/A

Key ActionObtain preauthorization before providing concurrent hospice and curative care to a beneficiary under age 21.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Under 21Maximum beneficiary age for concurrent care

6 monthsRequired terminal illness life expectancy

PreauthorizationConcurrent care utilization requirement

3 daysInitial care-plan completion deadline

Every 15 days

Care-plan review frequency

WeeklyCare-coordination meeting frequency

Concurrent Hospice and Curative Care Coverage

Concurrent hospice and curative care criteria

Covered when all of the following are met:

ALL of the following

Beneficiary is TRICARE-eligible and under age 21Under age 21
Concurrent care eligibility ends when the beneficiary turns 21.
Beneficiary has a terminal illness with a life expectancy of six months or less if the terminal illness runs its normal courseSix months or less
Beneficiary has elected the TRICARE Hospice Benefit for the terminal illness
Referring health care provider has identified the beneficiary for referral to a participating hospice
Signed and dated certification or attestation of the terminal illness has been obtained from the referring provider and hospice medical director
Beneficiary meets hospice eligibility and admission criteria
Curative treatment is medically necessary, related to the terminal illness, and otherwise covered under the TRICARE Basic Program
Services are provided by authorized TRICARE hospice, individual, non-institutional/non-professional, or institutional providers

Eligibility and preauthorization criteria

Concurrent curative care is eligible when all beneficiary and authorization requirements are satisfied:

ALL of the following

Beneficiary is under age 21Under age 21
Beneficiary has a terminal illness with a life expectancy of six months or less if the terminal illness follows its normal courseSix months or less
Referring health care provider has identified the eligible beneficiary for referral to a participating hospice
Signed and dated terminal-illness certification or attestation has been obtained from the referring provider and hospice medical director

Covered curative treatment

Covered curative treatment must satisfy all applicable TRICARE Basic Program requirements:

ALL of the following

Treatment is medically necessary and related to the terminal illness for which hospice care was elected
Treatment is provided by an authorized provider category under the applicable TRICARE requirements and by a provider authorized under the TRICARE Basic Program
Eligible settings include professional and other non-institutional/non-professional providers, and institutional providers in both inpatient and outpatient settings.
All applicable Basic Program conditions for coverage are met
Treatment is billed to the contractor for non-hospice reimbursement under the applicable Basic Program methodology

Coordination and medical-review criteria

Concurrent care requires coordinated documentation, ongoing medical review, and controls against duplicate or overlapping services:

ALL of the following

A consolidated treatment plan coordinates hospice palliative services with curative services and supports shared decision-making
A monthly service and activity log documents the primary diagnosis and comorbidities, palliative and curative services provided, staff categories, and the number and length of visits
Hospice and outside curative providers coordinate care and case management
The consolidated treatment plan and monthly service and activity log are available for contractor medical review and evaluation
Services are medically necessary, appropriate, and reasonably consistent with the consolidated plan of care

Reimbursement and exclusion rules

Payment is available under Basic Program rules when all of the following apply:

ALL of the following

Curative treatment is paid under the standard Basic Program methodology for the provider category and setting
CMACs apply to professional services; DRGs apply to institutional care.
Established cost-sharing and deductible provisions apply
Basic Program curative reimbursement is not subject to hospice payment or inpatient limits
The beneficiary is not a TRICARE Overseas Program beneficiary
TRICARE Overseas Program beneficiaries are not subject to this policy.

Coding, Reimbursement, and Operational Limits

Covered Basic Program Reimbursement MethodologiesmixedCovered

CMAC	CHAMPUS Maximum Allowable Charges used for professional curative services
DRG	Diagnostic Related Group methodology used for institutional curative care

Beneficiary age

Eligibility ageBeneficiary must be under age 21

Eligibility endpointEligibility ends when the beneficiary turns age 21

Care coveredMedically necessary curative treatment related to the terminal illness may be provided in addition to hospice palliative care

Terminal illness life expectancy

Life expectancySix months or less

ApplicabilityThe criterion applies when the terminal illness follows its normal course

Care relationship

Authorization, Documentation, and Billing Responsibilities

Prior Authorization

Preauthorization Required for Concurrent Care

Preauthorization is required for coverage and reimbursement of concurrent hospice and curative care for beneficiaries under age 21. Obtain authorization before providing or billing concurrent care so the contractor can verify eligibility and coordinate the hospice and outside providers.

Documentation Required

Eligibility and Certification Documentation

Submit documentation supporting the beneficiary’s eligibility for concurrent care and hospice admission. The record must establish the beneficiary’s age, terminal illness, prognosis, referral, certification, and hospice eligibility.

Beneficiary is under age 21 and has a terminal illness with a life expectancy of six months or less if the illness follows its normal course.
Referring health care provider has identified the beneficiary for referral to a participating hospice.
Obtain a signed and dated certification or attestation of terminal illness from both the referring provider and hospice medical director.

Key Terms

Concurrent care

Concurrent careHospice services and medically necessary curative TRICARE Basic Program services provided concurrently

Condition treatedThe services are provided for the same terminal condition

Hospice roleHospice services provide palliative services and support while curative treatment remains covered

Curative treatment

Program coverageTreatment covered under the TRICARE Basic Program

Medical necessityThe treatment must be medically necessary

Relationship to hospice

Policy Summary

PayerDHA

PolicyConcurrent Hospice and Curative Care for Pediatric Beneficiaries

Policy CodePolicy 4.0

Change TypeNo material change

Effective DateDec 12, 2017

Next Review DateN/A

Key ActionObtain preauthorization before providing concurrent hospice and curative care to a beneficiary under age 21.

SourceLink

On This Page

Beneficiary meets hospice eligibility and admission criteria

Concurrent hospice and curative care has been preauthorized

Preauthorization is required before coverage and reimbursement of concurrent care.

Services are classified as curative or palliative based on the beneficiary's individual circumstances and, when needed, physician orders or the consolidated plan of care

Services are not duplicative or overlapping

Duplicate claims may be rejected or denied, including through post-payment medical review.

The curative treatment must be related to the terminal illness for which hospice care was elected

Concurrent-care age limit

Age requirementBeneficiary must be under age 21

Concurrent-care endpointConcurrent care ends when the beneficiary turns age 21

Eligible treatmentMedically necessary curative treatment remains covered under the TRICARE Basic Program when related to the terminal illness

Terminal illness life expectancy

Life expectancy requirementSix months or less

Normal-course standardThe terminal illness must have a life expectancy of six months or less if it runs its normal course

Additional careEligible curative treatment is provided in addition to palliative hospice care

Initial consolidated plan completion

Initial completion deadlineWithin 3 calendar days of referral

Responsible documentThe consolidated plan of care must require coordination and case management

Plan contentThe plan must provide a detailed breakdown of hospice and curative services

Consolidated plan review frequency

Review frequencyAt least every 15 calendar days

Required actionThe consolidated plan of care must be reviewed, revised, and documented

Applicable standardThe review cadence is required by the hospice conditions of participation

Care-coordination meetings

Meeting frequencyWeekly

Permitted formatsTelephonically or in person

Meeting purposeHospice and curative-provider counterparts review and revise the beneficiary's consolidated plan of care as necessary

Additional hospice episodes

Qualifying eventThe terminal disease later returns or a new condition reduces life expectancy to six months or less

Additional episodesTwo additional 90-day episodes of care

Subsequent periodsAn unlimited number of 60-day periods follows the two additional episodes

Document that the beneficiary meets hospice eligibility and admission criteria.

Prior Authorization

Contractor Authorization Determination

The contractor performs the preauthorization review, including verification of eligibility and coordination requirements, and makes the authorization determination. The contractor must manage and resolve inquiries concerning the review and resulting final determination.

Contractor enhanced case management must support collaboration among the hospice and providers or suppliers furnishing curative services.
Authorization or denial is issued after the preauthorization review is complete.

Billing Rule

Bill Concurrent Curative Services Through the Basic Program

TRICARE Basic Program services that are normally curative and relate to the terminal illness must be billed to the contractor for non-hospice reimbursement during the hospice election. This reimbursement is in addition to applicable non-hospice reimbursement for direct patient care and treatment of unrelated conditions.

Covered curative care may be furnished by authorized professional, non-professional, institutional inpatient, and institutional outpatient providers.
Use the standard Basic Program reimbursement methodology for the provider category and care setting.

Billing Rule

Payment Treatment During Hospice Election

Basic Program coverage for eligible beneficiaries under age 21 does not require revocation of the hospice election. Payment for these services is not subject to hospice payment limits or inpatient limits, although applicable Basic Program cost-sharing and deductible provisions continue to apply.

Continued coverage is available while TRICARE Hospice Benefit coverage remains elected.
If curative care succeeds and the hospice election is later revoked, special episode-of-care rules may apply if the terminal condition returns or a new qualifying condition develops.

Prior Authorization

Authorization Must Precede Care and Billing

Ensure authorization is obtained before concurrent hospice and curative services are delivered or billed. Do not begin or submit concurrent care until the contractor’s preauthorization process has been completed.

Preauthorization supports verification of eligibility and collaboration between the hospice and referring outside providers.
The requirement applies to coverage and reimbursement of concurrent care.

Documentation Required

Authorization Determination and Notice

After completing the preauthorization review, the contractor must communicate the determination and handle related inquiries through the final decision. Distribute the authorization or denial letter to the referring health care provider, hospice, and beneficiary.

Issue an authorization or denial letter once the determination is made.
Maintain a process for managing and resolving inquiries about the review and final determination.

Documentation Required

Identify Outside Curative Providers and Submit Records

Identify every outside provider or supplier furnishing curative treatment and include those providers in the consolidated treatment plan and monthly service and activity log. Submit the plans, logs, and any additionally requested medical documentation to the contractor.

The hospice must notify the contractor of outside providers rendering curative treatment.
Records must support integration of hospice and curative services and allow reimbursement to the appropriate authorizing provider.
Submit documentation monthly and whenever additionally requested.

Documentation Required

Coordinate and Document Concurrent Services

Maintain a consolidated treatment plan for concurrent hospice and curative care and coordinate services across the hospice and outside providers. Track actual care and support shared decision-making through documented case management and communication.

Include both palliative and curative services, the staff categories providing them, and the number and length of visits.
Conduct ongoing communication and education with the beneficiary and family about treatment plans and options.
Designate staff responsible for interactions with outside providers and maintain mechanisms to resolve care-coordination conflicts.

Documentation Required

Maintain Required Care-Plan Cadence

Complete the consolidated plan of care within three calendar days of referral, then review, revise, and document it at least every 15 calendar days. The hospice care coordinator and appropriate interdisciplinary team members must meet weekly with curative-provider counterparts to review and revise the plan as needed.

Track care in a monthly service and activity log.
Submit the consolidated plan and service/activity log to the contractor monthly.
Ensure the plan provides a detailed breakdown of hospice and curative services.

Denial Risk

Avoid Duplicate or Overlapping Billing

Use claims and care-management controls to prevent payment for duplicate or overlapping hospice and curative services. The contractor may identify and deny duplicative services during post-payment review, and duplicate claims must be rejected.

Compare consolidated plans of care, monthly service and activity logs, medical records, and claims data.
Maintain internal controls for duplicate claims and address inconsistencies or overlap between providers.

Unsupported block type: billing_rule

The treatment must be related to the terminal illness for which hospice care was elected

Concurrent care

Concurrent careMedically necessary curative treatment related to a terminal illness is provided in addition to palliative hospice care

Eligible beneficiaryThe beneficiary must be under age 21

Reimbursement basisCurative treatment is reimbursed under the TRICARE Basic Program

Curative treatment

PurposeCurative services are intended to treat the beneficiary's condition

Classification standardWhether a service is curative is determined case by case

Documentation consideredPhysician orders or the consolidated plan of care may help determine the service's purpose

Palliative services

DefinitionPalliative services are hospice services and support

Beneficiary supportThey are intended to help children and families live as normally as possible

Needs addressedThey address the physical, emotional, social, and spiritual aspects of suffering

Duplicative services

DefinitionDuplicative services are the same or overlapping services

Providers involvedThe services may be provided by both the hospice and a referring health care provider or other TRICARE-authorized provider

Payment consequenceDuplicate claims must be rejected and duplicative services are subject to denial through medical review