Provider Alerts

Effective Immediately HPSJ/MVHP is aligning its claims processing and billing practices for hospice services with updated guidance from the Department of Health Care Services (DHCS), including All Plan Letter (APL) 25-008 and the Medi-Cal Provider Manual.

Please follow the requirements below to ensure proper claim submission and timely reimbursement.

PROVIDER ELIGIBILITY REQUIREMENTS

To qualify for reimbursement, hospice providers must:

• Be licensed by the California Department of Public Health (CDPH)
• Be Medicare-Certified
• Be enrolled in Medi-Cal
• Be credentialed and contracted with HPSJ/MVHP

DOCUMENTATION REQUIREMENTS

Hospice providers are responsible for:

• Submitting the Medi-Cal Hospice Program Election Notice and addendum to the health plan within five (5) calendar days of the member’s election of hospice services. You may fax to 209-762-4720.
• Ensuring documentation includes:

• • Certification of terminal illness signed by the hospice medical director and attending physician (if applicable).
  • Written plan of care.
  • Documentation supporting the level of care provided, especially for inpatient services.

Failure to submit timely election documentation may result in non-payment for days of service prior to receipt.

BILLING REQUIREMENTS

• Claims must be submitted using the UB-04 form or its electronic equivalent.
• Revenue codes must match the level of care provided, including:

• • 0650–0659: Routine, respite, inpatient, and continuous care

• • 0657: Hospice physician services
  • 0658: Room and board

• Accurate Place of Service (POS) codes must be used:

• • 12 (Home), 21 (Inpatient Hospital), 31 (Skilled Nursing Facility), 32 (Nursing Facility)

MEMBER ELECTION & REVOCATION RIGHTS

• Members (or authorized representatives) may elect hospice services for initial 90-day periods followed by unlimited 60-day benefit periods.
• Members may revoke hospice at any time, which must be documented via a signed revocation form submitted to the plan within 5 days. You may fax to 209-762-4720.
• Members may change their hospice provider once per benefit period.

MCP COVERAGE AND PAYMENT

• HPSJ/MVHP must pay hospice providers no less than the Medicare hospice rates.
• Payment is based on the level of care, benefit period, and service setting.
• Routine home care rates are split into high (first 60 days) and low (day 61+), with service-intensity add-ons for the final seven days of life.
• Room and board for hospice services in SNF or ICF settings is reimbursed under Revenue Code 0658 and must include the facility information where the member resides.

PHYSICIAN SERVICES

• Reimbursable under Revenue Code 0657.
• Must be related to the terminal illness and provided by hospice-employed or contracted physicians.
• Limited to one visit per day per member.

UTILIZATION REVIEW

• Only general inpatient hospice care requires prior authorization.
• Other levels of hospice care (e.g., routine, respite, continuous home care) must not be subject to prior authorization but may be reviewed for medical necessity.

To view APL 25-008 for Hospice Services and Medi-Cal Managed Care please utilize the link below:

https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL%202025/APL25-008.pdf

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org