26-280 Avoid Claim Denials: Critical Reminder for Long‑Term Care
Date: 03/06/26
Required actions for hospice coordination and member transfers
This is a critical reminder for long-term care (LTC) facilities regarding required steps to avoid claim denials and financial liability when coordinating hospice care for Medi‑Cal members. Failure to follow these requirements may result in nonpayment of hospice services and loss of LTC room and board reimbursement.
Key policy reference
This guidance is based on All Plan Letter (APL) 25-008: Hospice Services and Medi Cal Managed Care, which outlines Managed Care Plan (MCP) (i.e., Health Net, on behalf of Community Health Plan of Imperial Valley) and physician, practitioner, and other provider responsibilities for hospice coordination.
Hospice providers must be in network
APL 25‑008 confirms that MCPs may limit hospice coverage to in‑network providers, except when medically necessary services are not available in network.
Important implications
If an LTC facility transfers a member to an out-of-network hospice provider:
- The Plan is not required to pay for hospice services.
- No payment will be issued unless a Single Case Agreement (SCA) or Letter of Agreement (LOA) is fully executed.
- Claims submitted without an approved SCA/LOA will be denied.
Long-term care liability for out‑of‑network hospice care
Under APL 25‑008, MCPs are not obligated to pay for hospice care days when:
- The hospice provider is out-of-network and no SCA/LOA exists, or
- Required hospice documentation is missing, incomplete or submitted late.
When this occurs:
- The Plan will deny payment for hospice services.
- The out‑of‑network hospice will not be paid.
- Because room and board reimbursement flows through the hospice provider, the LTC facility will also not receive payment.
Required actions for all long-term care facilities
Before initiating or transferring a member to hospice care, LTC facilities must:
1 Verify hospice network status.
Confirm the hospice provider is contracted with the Plan by contacting Community Health Plan of Imperial Valley Provider Services or using your facility’s contracting resources.
2 Submit required documentation timely.
Ensure all required documentation is fully completed and submitted within five calendar days of the hospice election date.
3 Coordinate with the Plan before transfer.
- Notify the Plan before transferring a member to hospice.
- If the member requests an out‑of‑network hospice provider, the LTC facility must notify the Plan.
- The Plan will determine whether an SCA/LOA may be initiated.
4 Avoid unauthorized or unverified transfers.
Do not transfer members to out‑of‑network hospice providers without Plan approval. Unauthorized or unverified transfers place the LTC facility at financial risk.
Types of long-term care facilities
Long‑term care facilities include, but are not limited to:
- Adult Group Homes/Adult Foster Care Homes
- Assisted Living Facilities (Residential Care Facility for the Elderly and Adult Residential Facility)
- Continuing Care Retirement Communities
- Independent Living (within senior communities)
- Intermediate Care Facilities
- Medical Foster Care
- Memory Care Facilities
- Nursing Homes/Skilled Nursing Facilities
Resources
To help support you, refer to the Hospice Services Documentation Guide (PDF), which outlines required documentation and submission timelines. You can also access the guide in the Provider Library > Medi-Cal > Forms and References > search for Hospice Services Documentation Guide.
For additional hospice coverage provider communications, visit the Provider Library > Medi-Cal > Provider Updates and Notices > search and review:
- 25-941, Updated Hospice Care Guidelines for Medi-Cal Providers
- 25-812, New Email for Hospice Documentation Submissions
This information applies to Physicians, Practitioners, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, and Enhanced Care Management (ECM) Providers.
This information applies to Medi-Cal in Imperial County.