CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hospice Care Services Coverage

Governs coverage, reimbursement, and documentation requirements for hospice services provided in home, inpatient hospice facility, SNF, hospital, and nursing home settings for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHospice Care Services Coverage

Policy CodePolicy N/A

Change TypeCoding update — removal

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization requirements; Neighborhood will authorize the first 30 days of hospice care in a nursing home for specified Medicaid members.

SourceLink

POLICY UPDATE CHANGES

G0299 and G0300 were removed from the coding grid.

30 daysinitial authorized hospice period (selected Medicaid members)

5 daysmaximum respite care admission length

1 yearbereavement counseling duration

Severalcoding entries listed

Coverage Criteria for Hospice Services

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General hospice coverage criteria

Covered when ALL of the following are met:

Medical necessity and eligibility: Services must be medically necessary and the provider must verify member eligibility, coverage and authorization criteria.

Neighborhood may use LCD, NCD, InterQual, RI EOHHS recommendations, and CMPs to determine medical necessity.

Settings: Hospice services are provided in the home, inpatient hospice facility, skilled nursing facility (SNF), hospital, and nursing home settings; respite care occurs in an inpatient setting.

Respite care cannot exceed 5 days per admission.

Medicaid coverage details

Medicaid-specific provisions:

Initial authorization for RHP/RHE members in nursing homes: Neighborhood will authorize the first thirty (30) days of hospice care for Rhode Health Partners (RHP) and ACA Adult Expansion (RHE) members when delivered in a nursing home setting.30 days

Starting on the first Medical Assistance fee-for-service reimbursement the hospice care and the room and board.

Room and board for long-term hospice care is not covered under Medicaid.

Respite care for adults: Respite Care is out of plan for adult members (22 and older) under Medicaid.

Respite care must occur in an inpatient setting and cannot exceed a 5 day admission.

Integrity product coverage

Integrity members: Hospice services except for LTSS room and board are Out of Plan (OOP) for Integrity members; Neighborhood will still cover in-plan services not covered by Medicare while member is receiving OOP hospice services.

Under Medicaid, room and board for long-term hospice care is not covered. This exclusion applies to Medicaid-funded long‑term hospice placements and means that reimbursement for facility room and board charges associated with long‑term hospice care will not be paid.

Hospice services are covered when they meet medical necessity and eligibility requirements and are delivered in approved settings (home, inpatient hospice facility, SNF, hospital, or nursing home). Providers must verify member eligibility, coverage, and any prior authorization requirements before initiating services; Neighborhood may use LCDs, NCDs, InterQual, RI EOHHS recommendations, and CMS materials to determine medical necessity.

For Medicaid members in nursing homes, Neighborhood will authorize the first 30 days of hospice care for Rhode Health Partners (RHP) and ACA Adult Expansion (RHE) members when delivered in that setting. Respite care is available in an inpatient setting but may not exceed 5 days per admission.

Specific Medicaid provisions include that room and board for long-term hospice care is not covered, and respite care is out‑of‑plan (OOP) for adult Medicaid members age 22 and older.

Coding and Reimbursement

Covered HCPCS/HCPCS-like and T-codes listedHCPCSCovered

Q5001	Hospice or home health care provided in home/residence
Q5002	Facility living
Q5003	Hospice care provided in nursing long-term care facility (LTC) or non-skilled nursing facility (NF)
Q5004	Hospice care provided in skilled nursing facility (SNF)
Q5005	Hospice care provided in inpatient hospital
Q5006	Hospice care provided in inpatient hospice facility
Q5007	Hospice care provided in long-term care facility
Q5009	Hospice or home health care provided in place not otherwise specified (NOS)
S9125	Respite care, in the home, per diem
S9126	Hospice care, in the home, per diem

1–10 of 16

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Respite care maximum inpatient days — 5 days

Maximum inpatient respite lengthRespite care must occur in an inpatient setting and cannot exceed a 5‑day admission.

Setting requirementRespite care must occur in an inpatient setting.

Applies toRespite care admission length limit applies to hospice respite admissions as described under Medicaid provisions.

Provider Responsibilities and Actions

Prior Authorization

Authorization and eligibility verification — Provider action

Neighborhood may require verification of member eligibility and prior authorization for certain services. For hospice services, Neighborhood will authorize the first 30 days of hospice care for Rhode Health Partners (RHP) and ACA Adult Expansion (RHE) members when delivered in a nursing home setting. Respite care must occur in an inpatient setting and cannot exceed a 5 day admission. It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services. Contact Provider Services at 1-800-963-1001 for questions related to this policy.

Neighborhood may authorize first 30 days of hospice for RHP and RHE members in nursing homes
Respite care inpatient only; <= 5 days
Providers must verify eligibility, coverage, and authorization before services
Provider Services: 1-800-963-1001

Documentation Required

Required documentation and claim submission — Provider action

Providers must maintain medical records that support services billed and the medical necessity of those services. Neighborhood reserves the right to request medical records for any billed service. Failure to provide requested documentation that supports billed services and medical necessity may result in claim denial or other corrective actions. Documentation should follow CMS standards and use industry coding standards (CPT, ICD-10-CM, HCPCS).

Maintain medical records supporting billed services and medical necessity per CMS standards
Use CPT, ICD-10-CM, and HCPCS Level II coding standards on claims
Failure to provide documentation may trigger record requests and potential claim denial

Denial Risk

Provider action callout (high importance)

High importance: Providers must respond promptly to record requests. If documentation supporting the billed services and medical necessity is not provided, Neighborhood may deny the claim or take other recovery actions. Timely filing and completeness of claims are required per contractual agreements and payer guidelines.

Respond promptly to medical record requests
Incomplete or untimely claims may be denied per contractually determined timely filing guidelines

OpenPayer

Hospice Care Services Coverage

Coverage Criteria for Hospice Services

Coding and Reimbursement

Provider Responsibilities and Actions

Background

Definitions