B9: Patient enrolled in a Hospice

Hospice:

• When a patient is diagnosed with a disease that cannot be treated and has a life expectancy of less than 6 months then the patient becomes eligible for hospice.
• When a patient is diagnosed with a disease that can be treated but due to life-threatening treatment, the patient denies taking the treatment and has a life expectancy of less than 6 months then also the patient becomes eligible for hospice.
• Once hospice care is chosen, the patient stops getting treatment to cure and control the disease. The patient will only get pain relief treatment.
• When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for hospice-related services.
• Hospice-related services performed by the "attending physician" who is employed/contracted by hospice, should be submitted to the hospice contractor.
• Hospice-related services of an "attending physician" who is not an employee of the designated hospice or does not receive compensation from the hospice for those services, should be submitted to Medicare part B with GV modifier.
• Any services provided to a patient that is not related to a hospice condition should be submitted to Medicare Part B with a GW modifier.

Denial Occurrence:

• This denial occurs when the patient is enrolled in hospice and the claim is not billed to Hospice or Medicare.
• This denial also occurs when the patient is enrolled in hospice and the claim is billed to Medicare Part B without GV or GW modifier. 
• When a patient is enrolled in hospice and the claim is billed to Medicare Part B then it is necessary to append GV or GW modifier.

On Call Scenario:

                                                Claim denied as patient enrolled in Hospice
                                                                                  ↓
                                                                May I get the denial date?
                                                                                  ↓
                                 May I have the start date and end date of the hospice enrollment?
                                                                                  ↓
                                          Check if DOS lies between hospice enrollment period
                                            ↙                                                                                  ↘
                                         No                                                                                   Yes
                                          ↓                                                                                       ↓
                     Could you please send the                                       Can I get the hospice information

               claim back for reprocessing since                           such as hospice name, NPI, mailing address
             patient not enrolled in hospice on dos?                                             & policy ID?
                                         ↓                                                                                        ↓

                           What is the TAT for                                                         May I get the Claim#

                                reprocessing?                                                                    & Call ref#? 

                                        ↓                                            

                          May I get the Claim#                          

                               & Call ref#?                                   

Important Notes & Actions:

• Please take action as per your process update. Below actions can be different from your process update.
• If the DOS does not lie between the hospice enrollment period and the rep sends the claim back for reprocessing then you can set the follow-up for the TAT provided by the rep.
• If the DOS lies between the hospice enrollment period and the rep provides the hospice information then you can update hospice as primary insurance and submit the claim.
• Sometimes, the insurance rep does not provide hospice information and gives NPI numbers. In such a scenario, use the NPPES website to obtain the hospice name and mailing address. Also, an SSN can be used as a policy ID. This NPI number can also be found on the Medicare portal under the hospice tab.
• If the DOS lies between the hospice enrollment period and the rep does not provide any information about hospice and there are no details of Medicare available then you can release the claim to the patient. But, work as per your client's instructions.
• If the denial occurs from commercial insurance and the patient is enrolled in a hospice on DOS then it needs to be billed to Hospice or Medicare if have proper details. Do not resubmit it to commercial insurance.

Prepare Notes:

Source of Status:

* Call Website EOB System

Clearing House Comment (Please make the changes if required):

Insurance Name:

*

Clearing House Name:

Insurance Phone#:

*

Rep Name:

*

Website Name:

*

Denial Date:

*

Start Date of Hospice:

*

End Date of Hospice:

*

Is DOS lies within hospice period?:

* Yes No

TAT for Reprocessing:

*

What Information Available?:

* Hospice Name and Policy ID Hospice Name and Payer ID Hospice Name, Policy ID and Payer ID Hospice Name, Policy ID and Mailing Address Hospice Name, Payer ID and Mailing Address Hospice Name, Policy ID, Payer ID and Mailing Address None

Name of the hospice:

*

Policy ID:

*

Payer ID:

*

Claim Mailing Address:

*

Additional Comment:

Claim Number:

*

Call Reference#

*

Action:

* Updated hospice information and resubmitted the claim Updated GW modifier and resubmitted the claim Updated GV modifier and resubmitted the claim Claim released to patient Need to allow time Need client assistance



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