CurrentMolina HealthcarePolicy N/A

Hospice services provider requirements and utilization review

Governs requirements for Molina Healthcare of California members to use participating hospice providers, documentation required from hospices, utilization review and exceptions for out-of-network authorization; applies to Molina members and participating hospice providers in California.

Policy Summary

PayerMolina Healthcare

PolicyHospice services provider requirements and utilization review

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit required hospice documentation including DHCS Hospice Election Notice, Hospice Certification, attending physician referral, licensing and enrollment, and face-to-face attestation starting with the third benefit period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5required hospice documentation items listed

30max face-to-face interval (days)

2x90 + 60dbenefit period structure

2fax number occurrences

Coverage criteria for hospice services

Eligibility for hospice services under California law

Covered when ALL of the following are met:

CA regulatory conditions: Member is certified as terminally ill in accordance with 42 CFR Part 418 Subpart B and voluntarily elects hospice care (or the member's representative elects) in lieu of other care; an election statement is filed with the hospice identifying the hospice, including the effective date and the signature, and acknowledging that adult hospice care is palliative (children under 21 may receive palliative and curative care at the treating physician's discretion); a plan of care is established before services are provided and conforms to 42 CFR Part 418 Subpart C.

References 22 CCR § 51349(c),(d),(g) and 22 CCR § 51489(e)

Members who are capitated to a Participating Provider Group in Sacramento, Los Angeles, Riverside, and San Bernardino Counties may be excluded from using Molina participating hospice providers when their Participating Provider Group has its own preferred hospice network or is at risk for hospice services. In those situations, any hospice claims that are the responsibility of a capitated Provider Group will be denied and redirected to that Provider Group.

All required hospice documentation listed in Molina’s notice must be received for claims to be processed; claims will be denied unless all required documents are received. Additionally, when a hospice claim is the contractual responsibility of a capitated Participating Provider Group, Molina will deny the claim and redirect it to that Provider Group.

Policy Summary

PayerMolina Healthcare

PolicyHospice services provider requirements and utilization review

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

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Provider responsibilities, documentation, and authorization

Prior Authorization

Out-of-network authorization

In specific circumstances, Molina or its delegated groups may authorize out-of-network access for medically necessary hospice services when needed to avoid delays or when required services are not available in-network.

Applies when medically necessary services are unavailable in-network or to prevent delays in care

Note

Provider network responsibility

Participating Hospice providers must maintain Medicare Hospice Certification and be listed in the Molina Provider Directory. Providers should confirm network status before delivering services and contact Molina for authorization questions.

Documentation Required

Required hospice documentation

Hospice providers must submit required documentation for each benefit period, including the DHCS Hospice Election Notice form, timely submission per DHCS requirements, the member's Hospice Certification for Terminal Illness, a written referral signed by the attending physician, hospice provider license/Medicare certification/NPI and Medi‑Cal enrollment, and face-to-face attestation starting with the third benefit period.

DHCS Hospice Election Notice form (timely submission per DHCS)
Member's Hospice Certification for Terminal Illness for the benefit period
Written referral to hospice signed by the member's attending physician
Copy of Hospice Provider license (CDPH), Medicare certification, NPI, and Medi‑Cal enrollment
Face-to-face encounter attestation by hospice physician or NP starting with the third benefit period; encounter within 30 days prior to start of the third and each subsequent benefit period

Denial Risk

Claims denial risk

Claims will be denied unless all required documents are received. Molina will conduct utilization review to confirm hospice criteria are met; additional medical records may be requested at any time.

Failure to provide all required documents may result in claim denials

Billing Rule

Capitated provider responsibility

Any hospice claims that are the responsibility of a capitated Provider Group (including outpatient, inpatient, or professional hospice services in specified counties) will be denied by Molina and redirected to that Provider Group.

Applies to capitated Provider Groups in Sacramento, Los Angeles, Riverside, and San Bernardino Counties and other groups responsible for hospice services

OpenPayer

Hospice services provider requirements and utilization review

Coverage criteria for hospice services

Coding and timing requirements

Provider responsibilities, documentation, and authorization

Regulatory background

Key definitions