23-578 Bill Medicare for Claims for Dual Coverage Members Enrolled in Hospice

Date: 06/23/23

Recoupment notices will be sent for affected claims

Per the Centers for Medicare & Medicaid Services (CMS), providers must only bill Medicare when members have hospice benefit through Medicare. Health Net is only responsible to pay supplemental services provided to hospice members. As a result, hospice claims that are paid by Health Net can be recouped when members are enrolled in hospice through Medicare.

Starting September 1, 2023, Wellcare By Health Net (Health Net*) will recoup inappropriately paid hospice claims for dual coverage members. Providers should seek payment from Medicare.

Exclusions

The following are excluded from recoupment:

• Medicare Part D and supplemental services.
• Modifier GW, Condition Code 07, Procedure Codes S5170 and S5161.

Provider notices

A recoupment notice will be sent to providers informing them of the overpayment. Providers will receive another notice after the claims have been adjusted with the recoupment information.

Provider should resubmit hospice claims to CMS for reimbursement.

Additional information

Providers are encouraged to access the provider portal for real‐time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact the Provider Services Center at 800‐929‐9224.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.