Currentpriority healthPolicy N/A

Hospice care

Defines hospice benefit eligibility, certification/recertification, documentation, place of service, billing/coding instructions and revenue/HCPCS code usage for Priority Health members (Commercial; Medicare follows CMS; Medicaid follows MDHHS).

Policy Summary

Payerpriority health

PolicyHospice care

Policy CodePolicy N/A

Change TypeAdministrative language update

Effective DateApr. 15, 2025

Next Review DateN/A

Key ActionObtain and document written certification (or timely oral certification followed by written) stating life expectancy ≤6 months with an individualized clinical narrative, include provider signature and benefit period dates before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Language revisions and removal of Medical Policy reference on 2025-08-28.

6 monthsmaximum stated prognosis for hospice eligibility

Two 90-day + unlimited 60-daybenefit period structure

34designated hospice POS code

UB-04required billing format for facility billing

Hospice eligibility and recertification

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Hospice eligibility and recertification criteria

Criteria that must be met to qualify for hospice benefits and to continue benefits for subsequent periods.

ALL of the following

Care is provided by a certified physician.
Attending physician and hospice physician certify the patient as terminally ill with a medical prognosis of six months or less if the illness runs its normal course.
A signed election statement of hospice benefits and waiver to all rights of Medicare payments for the terminal illness and related conditions.

ANY of the following

Benefit period options: two 90-day periods followed by unlimited number of subsequent 60-day periods.

ALL of the following

For recertification starting with the third benefit period and every subsequent recertification, a hospice physician or hospice nurse practitioner must have a face-to-face (FTF) encounter with the patient documenting clinical findings supporting life expectancy of six months or less.Face-to-face encounter requirement: Required before third benefit period and before each subsequent recertification
FTF encounter required before third benefit period and before each subsequent recertification; failure to meet requirement will result in loss of eligibility.
Failure to meet FTF encounter requirements will result in the patient no longer being eligible for the benefit.

ALL of the following

Certification must be written by the hospice medical director, a physician member of the hospice interdisciplinary group, or the patient's attending physician for each election period.
If written certification cannot be provided within two calendar days, oral certification must be obtained within two calendar days; written certification must be obtained before submitting a claim.Oral certification timeline: Oral certification must be obtained within 2 calendar days if written certification not available
Recertifications may be completed up to 15 days before the next benefit period starts.Recertification window: May be completed up to 15 days before next benefit period starts

Key timing & threshold requirements

Face-to-face encounter requirementRequired before third benefit period and before each subsequent recertification

Recertification windowMay be completed up to 15 days before next benefit period starts

Oral certification timelineOral certification must be obtained within 2 calendar days if written certification is not available

Codes, revenue & modifiers

Revenue codes (UB-04)RevenueCovered

0551	Skilled Nursing - Visit Charge (Pre-hospice visit-commercial plans only) (Prior Authorization Required)
0561	Medical Social Services - Visit Charge (Prior Authorization Required)
0651	Hospice Service - Routine Home Care (per diem)
0652	Hospice Service - Continuous Home Care (per hour)
0655	Hospice Service - Inpatient Respite Care
0656	Hospice Service - General Inpatient Care (Non-Respite)
0657	Hospice Service - Physician Services (Hospice Physician Service, bill with appropriate E&M CPT code; excludes routine management by hospice physician which is included in per diem reimbursement.)
0658	Hospice Service - Room & Board - Nursing Facility
0690	Pre-hospice/Palliative Care Service - General
0691	Pre-hospice/Palliative Care Service - Visit Charge

1–10 of 18

1/2

HCPCS hospice place-of-service codesHCPCSCovered

Q5001	Hospice or home health care provided in patient's home/residence
Q5002	Hospice 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
Q5008	Hospice care provided in inpatient psychiatric facility
Q5009	Hospice or home health care provided in place not otherwise specified (NOS)
Q5010	Hospice home care provided in a hospice facility - Not payable

ModifiersModifier

26	Professional Component
GV	Non hospice related
PM	Post mortem

Billing Rule

UB-04 and Part A revenue code billing

Hospice services billed under Part A revenue codes must be billed on a UB-04 either monthly or at the conclusion of treatment.

Affected codes: revenue codes from code_groups[0]
Format: UB-04

Billing Rule

Hospice vs non-hospice billing

All services pertaining to the terminal illness/condition(s) must be billed and compensated by the assigned/rendering hospice facility; other providers may bill only for services not pertaining to the terminal illness/condition(s).

Bill hospice services to assigned/rendering hospice facility; other providers bill only services not pertaining to the terminal illness/conditions.

Quick coding references

designated hospice POS codePlace of Service 34

required billing format for facility billingUB-04

Documentation, certification & submission requirements

Documentation Required

Certification content and narrative requirements

Written certification must state the patient’s life expectancy is six months or less and include specific clinical findings; an individualized narrative must appear above the provider signature (or be signed as an addendum) and must state it was composed from review of the record or exam.

Provider signature, date signed and benefit period dates required
Narrative must state provider composed it from review of record or exam.

Documentation Required

Face-to-face encounter documentation

For the third and each subsequent benefit period, a hospice physician or hospice nurse practitioner must perform and document a face-to-face (FTF) encounter with the patient that documents clinical findings supporting a life expectancy of six months or less.

Consequence: failure = loss of eligibility
Threshold: Required before third benefit period and before each subsequent recertification

Documentation Required

Required documentation elements

Maintain a complete medical record including physician-authenticated certification of terminal status, election of benefits statement, plan of care and physician orders, decline in clinical status worksheet, visit notes, admission nurse assessment, therapy evaluations, IDG discussions, supporting events and date of death if applicable; documentation must support the level of care billed.

Documentation must support level of care billed.

Documentation Required

Timing for claims submission

Hospice must obtain written certification before submitting a claim; if the certification date is missing, a notarized statement or other acceptable document from the provider may be used to verify the certification date.

If written certification unavailable within two calendar days, oral certification must be obtained within two calendar days (oral certification timeline).

Scope and clinical context

This policy defines hospice care benefits for Priority Health Commercial members and explains the clinical and documentation requirements that must be met to initiate and continue hospice coverage. Hospice care is defined as a type of palliative care for people who are terminally ill and for their families. The policy applies to Commercial members; Medicare follows CMS guidance and Medicaid follows MDHHS guidance. Relevant CMS articles and Local Coverage Determinations (LCDs), as well as external resources, are provided for additional guidance on determining terminal status and compliance requirements.

Policy Summary

Payerpriority health

PolicyHospice care

Policy CodePolicy N/A

Change TypeAdministrative language update

Effective DateApr. 15, 2025

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Hospice care

Hospice eligibility and recertification

Codes, revenue & modifiers

Documentation, certification & submission requirements

Scope and clinical context

Defined terms

Policy updates