Currentpriority healthPolicy N/A

Palliative care services coverage

Defines Priority Health coverage, limitations, and coding guidance for palliative care services across settings (home, facility, inpatient) and identifies non-covered services; applies to members whose benefits include this policy.

Policy Summary

Payerpriority health

PolicyPalliative care services coverage

Policy CodePolicy N/A

Change TypeTable deletion (operational)

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization for inpatient palliative care when services are subject to the Skilled Nursing/Rehabilitation/Inpatient Hospice benefit maximum days.

SourceLink

POLICY UPDATE CHANGES

Deletion: I.A.D. Table 1.

home, facility, inpatientsettings covered

PA requiredinpatient authorization

0690-0699non-covered revenue codes

2025-06-01effective

2009origin

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered Services

Covered when services meet the described settings and skilled‑need criteria:

General coverage: Priority Health covers palliative care including palliative care consultation, potentially curative treatments, and routine intermittent skilled services in the home and basic nursing/residential facilities; short-term inpatient care is covered when necessary for skilled nursing needs that cannot be provided in other settings.

Inpatient care provided in an acute care facility or skilled nursing facility is subject to the Skilled Nursing/Rehabilitation/Inpatient Hospice benefit maximum days and requires prior authorization.

Covered settings and skilled‑need requirements

Home setting: Routine intermittent skilled services are covered in the member's home for the member and his/her family.
Basic nursing home or residential facility: Routine intermittent skilled services are covered in a basic nursing home or residential facility; room and board is not a covered benefit.
Inpatient setting: Short‑term inpatient care is covered when necessary for skilled nursing needs that cannot be provided in other settings.
Inpatient care in an acute care facility or skilled nursing facility is subject to the Skilled Nursing/Rehabilitation/Inpatient Hospice benefit maximum days and requires prior authorization.

Non‑covered when non‑skilled: Services that are non‑skilled (homemaker/caretaker services, sitter/companion services, transportation, housecleaning, maintenance), respite care, and home health aide or custodial care without a skilled need are not covered when billed as skilled services.

Priority Health does not cover non-skilled personal support services when billed as skilled care. Non-covered service types include: homemaker/caretaker services, sitter/companion services, transportation, housecleaning, maintenance of the house, respite care, and home health aide or custodial care without a skilled need. These services may, however, be included in a per-diem agreement with a palliative care organization/provider and are not considered skilled nursing care for coverage purposes.

Experimental or investigational care and services are not covered under this policy.

Coding and Revenue References

ICD-10 Diagnosis CodesICD-10

not specified

list primary condition

Evaluation and Management CPT Codes (by setting)CPTCovered

99202-99215, 99242-99245	Office E/M codes
99221-99239, 99252-99255	Hospital E/M codes
99304-99316	Other facility setting E/M codes
99341-99350	Home E/M codes

Not Covered Revenue CodesRevenueNot Covered

0690	Pre-hospice/Palliative Care Service - General
0691	Pre-hospice/Palliative Care Service - Visit Charge
0692	Pre-hospice/Palliative Care Service - Hourly Charge
0693	Pre-hospice/Palliative Care Service - Evaluation
0694	Pre-hospice/Palliative Care Service - Consultation and Education
0695	Pre-hospice/Palliative Care Service - Inpatient Care
0696	Physician Services
0697	Reserved for Use by the NUBC
0698	Reserved for Use by the NUBC
0699	Pre-hospice/Palliative Care Service - Other

Revenue Code ReferenceRevenue

See policy 91023

Referenced revenue code guidance

Provider Requirements, Prior Authorization, and Billing Rules

Prior Authorization

Prior Authorization Required

Prior authorization is required for inpatient palliative care and certain other services. Submit PA requests through the Priority Health prior authorization process and include supporting documentation demonstrating medical necessity. Refer to the Priority Health Provider Manual for operational guidance and contact information for PA submission.

Prior authorization required for inpatient admissions when skilled nursing needs cannot be met in other settings
PA required for services subject to the Skilled Nursing/Rehabilitation/Inpatient Hospice benefit maximum days
Follow Priority Health Provider Manual for submission method and timelines

Documentation Required

Prior Authorization Documentation

Providers must submit documentation with PA requests that clearly demonstrates medical necessity. Include clinical assessments, skilled nursing notes, care plans, reason patient cannot be cared for in a lower level setting, and any relevant test results or consult notes.

Clinical rationale that skilled services are required and cannot be safely provided in the home or lower-acuity setting
Skilled nursing evaluations, visit notes, and frequency/duration requested
Relevant diagnostic results, physician orders, and interdisciplinary care plan

Denial Risk

Non-skilled Services Not Covered

Non-skilled services are not covered benefits and must not be billed as skilled care. These services may be included in per diem agreements with palliative care organizations but are not payable as separate skilled services.

Non-skilled homemaker or caretaker services (including sitter/companion services)
Transportation, housecleaning, and home maintenance
Respite care
Home health aide or custodial care when no skilled need is present

Denial Risk

Room & Board and Revenue Codes Not Covered

Room and board charges and specific pre-hospice/palliative care revenue codes are not covered and are at high risk for denial when billed separately.

Room & board charges in facilities (including basic nursing homes) are not covered unless skilled nursing needs exist and meet criteria for covered inpatient care
Revenue codes 0690–0699 (pre-hospice/palliative care service) are not covered

Billing Rule

Providers: ensure claims and prior authorization requests reflect only covered skilled services and include documentation to justify any inpatient level of care. Do not bill non-covered services separately as skilled care.

Do not bill homemaker, companion, transportation, housecleaning, maintenance, respite, or custodial care as skilled services
Include clear documentation when billing for inpatient skilled services to avoid denials

Background

Palliative care is patient- and family-centered care focused on optimizing quality of life by preventing and treating suffering across physical, emotional, social, and spiritual domains. Priority Health covers palliative care across settings — including consultation, potentially curative treatments, routine intermittent skilled services in the home, services in basic nursing/residential facilities (excluding room and board), and short-term inpatient care when necessary for skilled nursing needs that cannot be provided in other settings. Inpatient palliative care is subject to the Skilled Nursing/Rehabilitation/Inpatient Hospice benefit maximum days and requires prior authorization.

Definitions and Distinctions

Palliative care — definition

Core definitionPatient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering across physical, emotional, social, intellectual, and spiritual domains; no specific therapy is excluded from consideration.

Scope of servicesIncludes palliative care consultation and care provided across settings (home, hospital, skilled nursing facilities, nursing homes) by palliative care teams, hospice organizations, or specialists working alongside primary treating clinicians.

Care goalsRelief from distressing symptoms, easing of pain, and enhancing quality of life agreed upon by the patient, physicians, primary caregiver, and care team.

Provision flexibilityCan address physical, intellectual, emotional, social, and spiritual needs and facilitate patient autonomy, access to information, and choice.

Difference from hospice

Key distinction from hospicePalliative care may include potentially curative or disease-directed treatments, whereas hospice focuses on comfort when life-prolonging therapies are no longer effective or desired.

Life-expectancy requirementThere is no requirement for specific life-expectancy parameters for palliative care, unlike hospice eligibility criteria.

Settings and providersPalliative care is provided across settings (home, hospitals, skilled nursing facilities) by multidisciplinary teams or specialists working alongside primary clinicians.

OpenPayer

Palliative care services coverage

Coverage Criteria for Palliative Care Services

Coding and Revenue References

Provider Requirements, Prior Authorization, and Billing Rules

Background

Definitions and Distinctions