This Policy does not apply to FEP
Precertification is required for all Hospice admissions. The Member’s Benefit Plan language is the primary determinant of coverage.
General Inpatient Hospice care falls under the Member’s available Hospice Benefit, not the Member’s Inpatient Hospital Benefit.
Where permitted under the Provider agreement, initial admissions or additional days performed without preauthorization approval and on review of clinical documentation are determined by BCBSND to not meet criteria in this policy will be denied as provider-liable.
Please refer to the Member’s Plan Book for definitions.
Hospice – an organization that provides medical, social and psychological services in the home or inpatient facility as palliative treatment for patients with a terminal illness and life expectancy of less than 6 months.
For purposes of this policy, coverage, and reimbursement, the following levels of Hospice care are considered:
Various core services provided by Hospice, based on the individual member’s needs include:
Initial and Continued Hospice Admission
Coverage Criteria (Note: these are not Medical Necessity criteria, as the Hospice admitting Physician should already have determined medical necessity for Hospice prior to the preauthorization request)
Initial Hospice services may be covered when ALL of the following Points 1 through 3 are met.
Continued Hospice services may be covered beyond the initial approval period when the following Points are met:
If a patient improves and/or stabilizes sufficiently over time while in hospice such that he/she no longer has a prognosis of six months or less from the most recent recertification evaluation or definitive interim evaluation, that patient should be considered for discharge from the hospice benefit. Such patients can be re-enrolled when a decline in their clinical status is such that their life expectancy is again six months or less. On the other hand, patients in the terminal stage of their illness who originally qualify for the hospice benefit but stabilize or improve while receiving hospice care, yet have a reasonable expectation of continued decline for a life expectancy of less than six months, remain eligible for hospice care benefits.
Levels of Hospice Care
Hospice services are not a covered benefit when:
Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information.