Palliative Care — Coverage Criteria and Prior Authorization
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Defines coverage and eligibility criteria for palliative care services for Kern Family Health Care (KFHC) members and explains prior authorization process for providers.
No material clinical or coverage changes in this revision.
Palliative Care Coverage Criteria
Member Eligibility for Palliative Care
Covered when ALL of the following are met:
Each numbered item below must be satisfied
From policy item 1
From policy item 2
From policy item 3; definition of 'not in reversible acute decompensation' applies
From policy item 4
From policy item 5; qualifying illnesses listed
Palliative care is covered only when the member meets all eligibility criteria specified in the policy. Services do not apply to members who are eligible for hospice and have not declined hospice enrollment; palliative care applies when the member is not eligible for, or declines, hospice and the illness meets the criteria in APL 17-015. Documentation must show appropriate evidence of continued decline in health status and that the member has one or more qualifying advanced illnesses (for example, congestive heart failure, advanced cancer, COPD, or liver disease) as listed in policy guidance.
Provider Requirements and Authorization
Prior authorization required for palliative care
Prior authorization is required before providing palliative care services for KFHC members who may be eligible; providers must submit a prior authorization request for those members.
Operational contact for palliative care authorizations
Contact KFHC for operational questions or to initiate authorization; the policy lists a provider contact for additional information about the benefit and eligibility criteria.
- Provider contact: Alejandra Martinez at 661-617-2579
- General contact: Melissa Lopez, Provider Relations Manager 661-617-2642, melissa.lopez@khs-net.com
Document continued decline and hospice eligibility/decline
Document that the member has continued decline in health status and that they are not eligible for, or have declined, hospice enrollment; illness must meet all criteria listed in DHCS All Plan Letter 17-015.
- Record clinical evidence of continued decline in health status
- Document hospice eligibility status or explicit declination of hospice enrollment
- Reference APL 17-015 criteria for the qualifying illness
Submit prior authorization to avoid denial
Submit a prior authorization request for members who may be eligible for palliative care; failure to obtain required prior authorization may result in denial of services.
- Prior authorization requests should be submitted before initiating covered palliative care services
Background
Palliative care provides patient- and family-centered support to optimize quality of life by anticipating, preventing, and treating suffering in members with advanced illnesses. It is intended for members with progressive decline who are not in reversible acute decompensation and who are not eligible for, or who decline, hospice. For KFHC members who may be eligible, providers may submit a prior authorization request for palliative care services and should refer to DHCS All Plan Letter 17-015 for the full criteria and illness-specific requirements.
Definitions
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