CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hospice care coverage and reimbursement

Defines coverage, authorization, documentation, coding and reimbursement rules for hospice services for Neighborhood Health Plan of Rhode Island members across Medicaid, INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHospice care coverage and reimbursement

Policy CodePolicy N/A

Change TypeNo material content changes (review)

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization on Neighborhood's plan-specific Prior Authorization Reference page before rendering hospice services.

SourceLink

POLICY UPDATE CHANGES

Removed G0299 and G0300 from Coding grid.

Policy review on 03/19/2025 with no content changes.

30initial authorized hospice days (RHP/RHE)

5max respite inpatient days

1 yearbereavement counseling duration

Multiplelisted hospice billing codes

Coverage and Medical Necessity

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Hospice benefit coverage

Covered when services are medically necessary and meet hospice benefit definitions.

Basic hospice coverage: Services are covered as part of the hospice benefit when medically necessary; settings include home, inpatient hospice facility, skilled nursing facility (SNF), hospital, and respite services; covered services include physician services, nursing care provided by or supervised by a registered professional nurse, social work services, volunteer services, and counseling services (including bereavement counseling for the member's family for up to one year after the member's death).

Supported by chunks 0 and 3

Medicaid rules

Medicaid-specific rules.

Medicaid nursing home hospice initial authorization: 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; starting on day 31, Medical Assistance fee for service will reimburse the hospice care and the room and board.30 days

Chunk 4

Respite care restrictions: Respite care must occur in an inpatient setting and cannot exceed a 5 day admission.<= 5 days

Chunk 4

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

Chunk 6

Respite care out-of-plan for adults: Respite care is Out‑of‑Plan (OOP) for adult members (22 and older).

Chunk 6

INTEGRITY coverage

INTEGRITY members.

INTEGRITY coverage: For INTEGRITY members, hospice services except for LTSS and Room and Board are Out of Plan (OOP). Neighborhood will still cover in‑plan services that are not covered by Medicare while a member is receiving OOP hospice services.

Chunk 5

The Medicaid program does not cover room and board for long‑term hospice care. Providers should not bill Medicaid for room and board charges associated with long‑term hospice placements; these charges are excluded from coverage under Neighborhood’s Medicaid rules.

All hospice services must be medically necessary to qualify for reimbursement. Lack of documentation that demonstrates medical necessity or that does not support the services billed may result in denial of payment.

Providers are responsible for verifying member eligibility, coverage and authorization prior to rendering services and must maintain medical records that support billed services. Neighborhood may request medical records and follows CMS documentation standards; failure to meet these documentation requirements can lead to claim denials.

Billing Codes and Reimbursement Notes

Listed hospice and related billing codesmixed

Q5001	Hospice or home health care provided in patient's home/residence
Q5002	Hospice or home health care provided in assisted living facility
Q5003	Hospice care provided in nursing long-term care facility (LTC) or nonskilled 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

1/2

inv-07: Initial nursing home authorization — First 30 days authorized for RHP and RHE members

Authorized initial periodFirst 30 days of hospice care are authorized by Neighborhood for Rhode Health Partners (RHP) and ACA Adult Expansion (RHE) members when delivered in a nursing home setting

Post-authorization paymentStarting on day 31, Medical Assistance fee-for-service reimburses hospice care and room and board

Applicable settingAuthorization applies specifically when hospice care is delivered in a nursing home

inv-08: Respite inpatient length — <= 5 days

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

Setting requirementRespite care is required to be provided in an inpatient setting

Relation to coverageRespite admissions over 5 days are not authorized under this policy

Prior Authorization, Documentation, and Verification

Prior Authorization

Prior authorization required

Providers must verify member eligibility, coverage, and prior authorization requirements before rendering or billing for services. Prior authorization may be required for certain services or settings; check Neighborhood's plan-specific Prior Authorization Reference page for current requirements and the list of services that need authorization.

Verify eligibility and benefits before scheduling services
Confirm and obtain prior authorization when required

Note

Verify plan-specific rules and limits

Providers are responsible for confirming plan-specific authorization rules and any payer-specific prerequisites (for example, hospice prior authorization rules for RHP/RHE members). Failure to verify authorization requirements and member eligibility can lead to claim denials or payment delays.

Neighborhood will authorize the first 30 days of hospice care for RHP and RHE members in a nursing home; subsequent days billed to Medical Assistance fee-for-service
Respite care must occur in an inpatient setting and is limited to 5 days

Documentation Required

Medical record verification required

Medical records must fully support the services billed and demonstrate the medical necessity of each service. Neighborhood may request clinical documentation at any time; documentation must meet CMS standards for proper medical record content.

Maintain contemporaneous, legible clinical notes that justify billed services and levels of care
Retain authorization documentation and evidence that eligibility/coverage was confirmed prior to service delivery

Denial Risk

Denial risk for missing documentation or verification

Services lacking documentation that supports the billed services or medical necessity, or services rendered without verifying member eligibility or required prior authorization, may be denied or subject to recoupment. Providers should obtain and retain all necessary authorizations and supporting records to reduce denial risk.

Failure to verify member eligibility, coverage, or prior authorization risks claim denial
Insufficient or missing documentation may result in denial or request for repayment

OpenPayer

Hospice care coverage and reimbursement

Coverage and Medical Necessity

Billing Codes and Reimbursement Notes

Prior Authorization, Documentation, and Verification

Policy Background

Key Definitions