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Last Modified: 6/14/2022 Location: FL, PR, USVI Business: Part A

Claims overlap FAQ -- Hospice and Medicare Advantage

Q: The claim for my patient's dates of service (DOS) overlaps a Medicare Advantage plan and hospice elections period. Should I bill the hospice, traditional Medicare, or the Medicare Advantage plan?
A: Federal regulations require that MACs maintain payment responsibility for managed care enrollees who elect hospice.
While a hospice election is in effect, certain types of claims may be submitted to the MAC by either the hospice provider or a provider treating an illness not related to the terminal condition. The claims are subject to Medicare rules of payment.
Hospice services covered under the Medicare hospice benefit are billed by the Medicare hospice.
Institutional providers may submit claims to Medicare with the condition code "07" when services provided are not related to the treatment of the terminal condition.
Medicare Advantage plan enrollees that elect hospice may revoke hospice election at any time, but claims will continue to be paid by the MAC as if the beneficiary were enrolled in Medicare until the first day of the month following the date hospice election was revoked.
Beneficiary's hospice election period ended on 1/10/YY
Bill the MAC for claims for DOS 1/11/YY to 1/31/YY
Bill the Medicare Advantage plan for claims for DOS 2/1/YY and beyond
Refer to resolution tips for overlapping claims, which is the A/B and home health and hospice (HHH) MAC collaborative job aid on how to resolve and prevent overlapping claim situations.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.