Last Modified: 11/16/2023
Location: FL, PR, USVI
Business: Part A
First Coast understands Part A billing can be confusing. Situations when a patient is in a hospice election period can be even more challenging. In fact, many of our top claim rejects for Part A facilities are related to hospice situations. We've prepared this article to help you avoid common hospice claim rejects (e.g., U5235, C7010).
Providers should verify a beneficiary's Medicare eligibility at the time of or prior to admission to ensure the patient is eligible to receive the services covered by Medicare. Checking the beneficiary's eligibility records also ensures the facility or agency verifies whether the patient is receiving services from another entity that would cause an overlapping situation or not.
Medicare beneficiaries entitled to hospital insurance (Part A) who have terminal illnesses and a life expectancy of six months or less have the option of electing hospice benefits in lieu of standard Medicare coverage for treatment and management of their terminal condition. Only care provided by a Medicare-certified hospice agency is covered under the hospice benefit provisions.
During an inpatient stay, a patient may be diagnosed with a terminal condition and elect to go on hospice. Electing or revoking the Medicare hospice benefit is the beneficiary's choice. The patient or their representative may elect or revoke Medicare hospice care at any time in writing. The hospice cannot revoke the beneficiary's election, nor request or demand the patient revoke their election. If the patient revokes their hospice election, Medicare coverage of all benefits waived when hospice care was initially elected resumes under the original Medicare program.
Services related to the terminal condition are billed by the hospice agency to the appropriate home health and hospice 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
as the regional home health and hospice intermediary (RHHI). National Government Services (NGS)
is the RHHI responsible for Puerto Rico and the U.S. Virgin Islands.
• If the patient is not enrolled in hospice, file the claim to Medicare (First Coast)
• If the patient is enrolled in hospice and the services provided to the beneficiary are related to their terminal condition for hospice services, file the claim with the hospice agency listed on the beneficiary's records
• If the patient is enrolled in hospice and the services provided to the beneficiary are not related to their terminal condition for hospice services, file the claim to Medicare with condition code (CC) 07 (treatment of non-terminal condition for hospice patient)
• Note: Customer service representatives cannot assist you with eligibility information and are required by CMS to refer you to the IVR.
When a beneficiary elects hospice during an inpatient stay:
• Bill original Medicare for period before hospice election
• Patient status code is 51 (discharge to hospice medical facility)
• Discharge date is the effective date of hospice election
• Bill hospice for period of care after hospice election
When a beneficiary revokes hospice during an inpatient stay:
• Bill hospice for period up to hospice revocation
• Bill original Medicare for period after hospice revocation
• Admission date is same as the hospice revocation date
• Statement 'From date' is the same as the hospice revocation date
What are the reject reason codes you may receive?
Here are some codes you may receive if the beneficiary was or is enrolled in a hospice election period for the date of service(s).
• U5235 -- Definition: For PPS claims, the admission date falls within a risk GHO period, the dates of service fall within a hospice election period; and condition code '07' is not present on the claim.
-- Definition: The edited inpatient or outpatient claim has 'from/thru' dates that overlap a hospice election period and is not indicated as treatment of a non-terminal condition (condition code '07') or a MCCD/DMD Notice of Election (89a) 'from' date overlaps a hospice election period.
Steps you can take to correct this reject:
• Remember: Customer service representatives cannot assist you with eligibility information and are required by CMS to refer you to the IVR.
• If the patient is enrolled in hospice:
• Providers of all types whose claims are overlapping a hospice election should contact the hospice agency to determine if the services are related to the terminal illness.
• If related, payment arrangements should be made with the hospice agency.
• Services not related to the terminal illness should be billed to Medicare with CC 07.
Providers who suspect the hospice may no longer be in business and are unable to verify if their services are related, or if the hospice has failed to update the revocation indicator, should contact their MAC for assistance
• If the patient is not enrolled in hospice:
• Contact the hospice agency and ask them to submit their last claim for the beneficiary with occurrence code 42 and the date of disenrollment.
• Once the records are deleted or updated, refile the claim to Medicare
Steps to avoid hospice claims rejects:
• Verify beneficiary's benefits at admission or check-in
• Collect full beneficiary health insurance information upon each office visit, outpatient visit, and hospital admission
• Every 90 days for recurring outpatient services furnished by a hospital
• Verify beneficiary's eligibility prior to submitting claims to Medicare
• Verify if patient is or is not in or enrolled in hospice
• Review hospice resources thoroughly
• Use available resources online
• Develop and implement policies that ensure provider's responsibilities for eligibility are met
• Share information with staff
Federal regulations require 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 agency 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 CC 07 when services provided are not related to 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
The following First Coast resources can be beneficial to determine hospice enrollment and eligibility for a patient. Use these resources to help avoid hospice claim rejects.
The following CMS resources may beneficial as well:
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.