CurrentUnitedHealthcarePolicy CSNC.MP.102.04

Hospice Services (for North Carolina Only)

UnitedHealthcare Community Plan medical policy that applies only to the State of North Carolina and references North Carolina Medicaid Clinical Coverage Policy for medical necessity criteria for community-based hospice services. It lists applicable HCPCS codes for hospice services and clarifies state fee-schedule applicability.

Policy Summary

PayerUnitedHealthcare

PolicyHospice Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.102.04

Change TypeRoutine review; no coverage change

Effective DateJul 1, 2025

Next Review Date

Key ActionWhen determining medical necessity for hospice services in North Carolina, refer to and document criteria per North Carolina Medicaid Clinical Coverage Policy: Community-Based Services: 3D, Hospice Services; federal/state/contractual requirements govern if different.

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

1State-specific policy (North Carolina only)

9HCPCS codes listed

Coverage Summary

This UnitedHealthcare Medical Policy is titled Hospice Services (for North Carolina Only) and is identified as Policy Number CSNC.MP.102.04. The policy is effective July 1, 2025 and applies only to the State of North Carolina.

The policy is informational and provides guidance for interpreting UnitedHealthcare standard benefit plans for hospice services in North Carolina. It defers clinical medical necessity criteria to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy: Community-Based Services: 3D, Hospice Services, and states that federal, state, or contractual requirements govern in the event of a conflict with this policy.

Policy metadata

effective dateJuly 1, 2025

last reviewJuly 1, 2025

statusCURRENT

scope_summaryUnitedHealthcare Community Plan medical policy that applies only to the State of North Carolina and references North Carolina Medicaid Clinical Coverage Policy for medical necessity criteria for community-based hospice services.

coverage_stancemixed (informational; defers clinical criteria to NC Medicaid Clinical Coverage Policy; federal/state/contractual requirements govern)

Medical Necessity / Coverage Criteria

Coverage / Medical Necessity

Coverage and medical necessity determinations follow the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Community-Based Services: 3D, Hospice Services.

Refer to NC Medicaid Clinical Coverage Policy: Medical necessity clinical coverage criteria are governed by the North Carolina Medicaid Clinical Coverage Policy: Community-Based Services: 3D, Hospice Services (referenced document).
See North Carolina Medicaid, Division of Health Benefits, Clinical Coverage Policies: Hospice Services, 1A-30.
Governing requirement for benefit coverage: Benefit coverage is determined by federal, state, or contractual requirements which may differ from this policy; in the event of conflict, federal/state/contractual requirements govern.
Policy provided for informational purposes; check applicable federal, state or contractual requirements.

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Applicable Codes

Applicable HCPCS codes (reference only)HCPCS

G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes
G0300	Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes
G0493	Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes
G0494	Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes
T2042	Hospice routine home care; per diem
T2043	Hospice continuous home care; per hour
T2044	Hospice inpatient respite care; per diem
T2045	Hospice general inpatient care; per diem
T2046	Hospice long-term care, room and board only; per diem

Codes not on NC Medicaid Fee Schedule (may not be covered by NC Medicaid)HCPCSNot Covered

G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes
G0300	Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes
G0493	Skilled services of a registered nurse (RN) for observation and assessment, each 15 minutes
G0494	Skilled services of a licensed practical nurse (LPN) for observation and assessment, each 15 minutes

Codes labeled with an asterisk in this policy are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program; providers should verify the state fee schedule before billing.

Provider Actions & Billing Guidance

Documentation Required

Follow NC Medicaid Clinical Coverage Policy for medical necessity

When determining medical necessity for hospice services in North Carolina, refer to and document criteria per North Carolina Medicaid Clinical Coverage Policy: Community-Based Services: 3D, Hospice Services; federal/state/contractual requirements govern if different.

Billing Rule

State fee-schedule applicability

Codes labeled with an asterisk (G0299, G0300, G0493, G0494, T2046) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program; verify state fee schedule before billing.

G0299
G0300
G0493
G0494
T2046

Background & Definitions

This policy provides assistance in interpreting UnitedHealthcare standard benefit plans for hospice services in North Carolina and is provided for informational purposes only. It does not replace federal, state, or contractual coverage requirements.

For medical necessity clinical coverage criteria, the policy defers to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Community-Based Services: 3D, Hospice Services, and instructs that federal, state, or contractual requirements govern if they differ from this policy.

Term	Definition
Hospice care services	Services rendered by licensed health care professionals; not subject to FDA regulation.