Claim denial FAQ -- Claim denied for hospice

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Home ► faqs ► answers ► Claim denial FAQ -- Claim denied for hospice

Last Modified: 11/20/2024 Location: FL, PR, USVI Business: Part A, Part B

Claim denial FAQ -- Claim denied for hospice

Q. Why are my claims being denied for hospice involvement? I don’t work for a hospice.

A. Medicare Part B pays only for physician services not performed for the hospice-related condition or paid under arrangement with a hospice entity. Services related to the terminal condition are billed by the hospice facility to the appropriate home health intermediary (Part A).

First Coast, as the jurisdiction N Part A and B MAC (JN A/B MAC), does not process claims for hospice services. Florida hospice claims are processed by Palmetto GBA external link

as the regional home health intermediary (RHHI). National Government Services (NGS) external link

is the RHHI responsible for Puerto Rico and the U.S. Virgin Islands.

First Coast does process claims for Part B providers who provide services to patients who are in a hospice episode, but the providers are not employed by or paid under arrangement with the hospice entity or the services provided are not related to the hospice patient's terminal condition.

If the physician billing hospice-related services is not employed or paid through an arrangement by the hospice entity, the services should be billed with a modifier GV (which indicates "Attending physician not employed or paid under arrangement by the patient's hospice provider"). Physician services not related to the patient's hospice condition must be billed with modifier GW (which indicates "Service not related to the hospice patient's terminal condition".)

Source: CMS IOM Pub. 100-04 Medicare Claims Processing Manual, chapter 11, section 40 external pdf file

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