Once a member begins receiving hospice services, all care for their terminal illness will be coordinated by the hospice organization. A review of our records indicates that hospice services for our members who have commercial or Medicaid Managed Care coverage may have been reimbursed improperly by the Health Plan. The hospice organization that provided the services should have been the responsible payer.
Effective immediately, when billing for services unrelated to the patient’s terminal condition, or if you are the hospice attending physician not employed or paid under the agreement by the hospice, one of the following values must be included with your submission to ensure that our claims processing system can identify these services:
Modifier GV (Attending physician not employed or paid under the agreement by
the patient’s hospice provider)
Modifier GW (Service not related to the hospice patient’s terminal condition)
Condition Code 07 (treatment of non-terminal condition for hospice)
Tips for Submitting claims
If the service is related to the member’s terminal condition, or the doctor is the attending hospice physician and employed or paid under the agreement by the hospice, submit the claim to the regional hospice program.
If the service is not related to the member’s terminal condition, or if the doctor is the hospice attending physician and not employed by the hospice, submit the claim to the Health Plan and include the proper Modifier (GV, GW, Condition code 07).
Thank you for the quality care that you provide to our valued members. If you have questions, please contact your Provider Relations representative.