Hospice: Non-Attending Physician Denials
Denial Reason, Reason/Remark Code(s)
- PR-B9: Patient is enrolled in a Hospice
- Procedures: All
- Prior to submitting claims to Medicare, determine whether the patient has elected hospice benefits
- You may verify eligibility through the Palmetto GBA Interactive Voice Response (IVR) unit or online though an ANSI 270/271 transaction
- If the patient has elected hospice benefits, refer to 'Hospice Benefits and Medicare Part B' section below
Hospice Benefits and Medicare Part B
- 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
- When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force, except for professional services of an attending physician, which may include a nurse practitioner
- Claims from the attending physician for services provided to hospice-enrolled patients may be submitted to Palmetto GBA with HCPCS modifier GV if the services are related to the terminal illness. HCPCS modifier GV signifies that:
- The service was rendered to a patient enrolled in a hospice
- The service was provided by a physician or nurse practitioner identified as the patient’s 'attending physician' at the time of that patient’s enrollment in the hospice program
- If the service was provided by a physician employed by the hospice, HCPCS modifier GV may not be submitted
- If the service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician, HCPCS modifier GV may not be submitted
- Any covered Medicare services by the attending or rendering provider that are not related to the treatment of a terminal condition for which hospice care was elected, and which are furnished during a hospice election period, may be submitted with HCPCS modifier GW. HCPCS modifier GW signifies that the service was not related to the hospice patient's terminal condition
Online Eligibility Verification
CMS offers real-time Internet-based eligibility transactions as an alternative to the IVR. These ANSI 270/271 transactions are processed through the CMS data center. Providers and clearinghouses must be authenticated by CMS before conducting these transactions. Telecommunications software is also required in order to access the CMS network.
Steps to obtain access for Internet eligibility (270/271) transactions:
- Access the CMS HIPAA Eligibility Transaction System (HETS)
- From the left navigation menu, select Sign Up Now
- In order to obtain access to the CMS 270/271 Medicare Eligibility transaction from the Medicare Data Communication Network (MDCN), you must access and complete the Trading Partner Agreement and Access Form
- This agreement outlines security and privacy procedures for the Medicare beneficiary database. Complete all the information on the form electronically and click on the appropriate assurances. If you do not consent to the terms of the agreement, the access process will be terminated.
- If you check the appropriate boxes of the agreement and supply the information requested, a copy of the completed form will be electronically submitted to the CMS 270/271 Medicare Eligibility Integration Contractor (MEIC) for security authentication
- The access process will then continue, and you will be directed to complete the MDCN Connectivity Form. This form must be submitted electronically in order for you to be connected to the 270/271 eligibility database.
- CMS will ensure that all necessary information is provided on the forms and ensure the complete connectivity to the 270/271 application. The MEIC will be responsible for contacting the clearinghouses, providers and trading partners to authenticate the accessing entity's identity. Once authentication has been completed, the MEIC will provide you with a submitter ID that must be used on all 270/271 transactions. Testing will be coordinated by the MEIC. After successful testing, 270 production inquiries may be sent in real-time.
- For more information about hospice coverage and claim submission, refer to the Palmetto GBA Physician/Supplier Guide. Select 'Publications' on the left side of this Web page.
- Access CMS guidelines related to hospice through the following links:
- CMS Pub. 100-02, chapter 9
- CMS Pub. 100-04, chapter 11, section 40 and 50