CurrentUnitedHealthcarePolicy CSNC.MP.102.04

Hospice Services (for North Carolina Only)

Defines UnitedHealthcare Community Plan policy for hospice services applicable to North Carolina Medicaid members; references NC Division of Health Benefits clinical coverage policy for medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

PolicyHospice Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.102.04

Change TypeRoutine review (no material change)

Effective DateJuly 1, 2025

Next Review Date

Key ActionRefer to the North Carolina Medicaid Clinical Coverage Policy for Hospice Services to determine medical necessity.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines

North Carolinaapplies only to

2025-07-01effective

NC Medicaid 1A-30clinical source

HCPCS/G/T listcodes referenced

Coverage and Medical Necessity Criteria

Medical Necessity (see NC Medicaid policy)

Policy Summary

PayerUnitedHealthcare

PolicyHospice Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.102.04

Change TypeRoutine review (no material change)

Effective DateJuly 1, 2025

Next Review Date

Key ActionRefer to the North Carolina Medicaid Clinical Coverage Policy for Hospice Services to determine medical necessity.

SourceLink

On This Page

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Inclusion of a procedure or diagnosis code in this policy is for reference only and does not imply that the service described by the code is a covered health service. Benefit coverage and reimbursement are determined by applicable federal, state, or contractual requirements and laws; those governing rules may require coverage for a specific service or may exclude it. The listing of a code in this document does not guarantee claim payment or confer any right to reimbursement.

Applicable Billing Codes & Fee Schedule Notes

Applicable HCPCS/G/T Codes (reference)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.

State fee schedule exclusion

NC Medicaid fee schedule exclusionCodes marked with an asterisk (*) in the applicable codes list 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.

Codes marked with *G0299, G0300, G0493, G0494, T2042, T2043, T2044, T2045, T2046 are each shown with an asterisk in the policy's Applicable Codes list indicating exclusion from the NC Medicaid fee schedule.

Listing is informationalInclusion of a code in this policy does not imply that the service described by the code is a covered health service or guarantee reimbursement; benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

Provider Responsibilities and Billing Guidance

Billing Rule

Code Listing and Billing Notice

Listing of procedure and diagnosis codes in this policy is for reference only and does not itself determine coverage or guarantee payment. Benefit coverage and billing requirements are governed by applicable federal, state, and contractual rules; providers must reference those governing requirements when submitting claims. Inclusion of a code in this policy does not imply coverage, reimbursement entitlement, or payment. Other policies and guidelines may apply.

Affected codes (informational): G0299, G0300, G0493, G0494, T2042, T2043, T2044, T2045, T2046
Providers must verify prior authorization and billing rules per the member's plan and governing requirements
Other Policies and Guidelines (e.g., Home Health, Skilled, and Custodial Care Services; Private Duty Nursing Services) may apply

Step Therapy

Step Therapy Not Specified

This policy does not specify any step therapy requirements. If a member's plan includes step therapy requirements, those federal/state/contractual rules take precedence and must be followed. Providers should verify plan-specific utilization management rules prior to initiating services.

Step therapy: Not specified in this policy — verify plan-specific requirements

Note

Follow Governing Contractual and State Requirements

Providers must reference federal, state, and contractual benefit requirements when determining coverage and prior authorization needs. In the event of any conflict between this policy and governing rules, the federal, state, or contractual requirements govern. UnitedHealthcare may use third-party clinical criteria (e.g., InterQual) to assist in benefit administration.

Verify prior authorization and documentation requirements per the member's plan and governing rules
When in doubt, follow federal/state/contractual requirements over this policy

Note

Code Inclusion is Informational Only

The codes shown in this policy are informational and do not imply coverage or guarantee payment. Inclusion is not authorization to bill or an admission of coverage. Providers should consult the member's benefit plan, contract language, and applicable laws to determine coverage and payment.

Code inclusion ≠ coverage determination or payment guarantee
Reference governing rules and any related UnitedHealthcare policies for billing guidance

Definitions

Definition and governing clinical coverage policy

Definition of hospice care servicesHospice care services are services rendered by licensed health care professionals and, therefore, are not subject to FDA regulation.

Coverage and medical necessity authorityMedical necessity clinical coverage criteria for hospice services are governed by the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Community-Based Services: 3D, Hospice Services; this policy directs readers to that NC Medicaid policy for full medical necessity criteria.

Use for providersProviders should refer to the referenced NC Medicaid clinical coverage policy to determine coverage and medical necessity requirements for hospice services under North Carolina Medicaid.

Background

Hospice care services are delivered by licensed health care professionals and are governed by the clinical coverage criteria set forth by the North Carolina Medicaid Division of Health Benefits. Medical necessity for hospice services in this policy is determined by reference to the NC Medicaid clinical coverage policy; providers should follow those referenced clinical criteria when assessing eligibility and coverage for hospice services.

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