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26-289 Support Timely Outpatient Hospice Care Admissions and Reimbursement

Date: 03/05/26

Medi-Cal PPGs are required to submit complete hospice documentation to Health Net within five calendar days when Health Net is at financial risk for hospice

When Health Net is at financial risk for Medi-Cal outpatient hospice services and a member begins outpatient hospice care, participating physician groups (PPGs) are required to submit complete hospice documentation directly to Health Net within five calendar days.

What you need to do

When Health Net is at financial risk for Medi-Cal outpatient hospice services, follow these steps:

  1. Submit complete hospice documentation directly to Health Net (see list below) within five calendar days via encrypted email.
  2. Do not issue prior authorization for outpatient hospice services. Prior authorization is not allowed for outpatient hospice services, per the California Department of Health Care Services.
  3. If a requested outpatient hospice provider is not participating with
    Health Net, you must redirect the member to a participating hospice provider.

PPG-issued prior authorizations when Health Net has financial risk

If a PPG issues prior authorization for Medi-Cal outpatient hospice services for which Health Net is at financial risk, Health Net may deduct the cost of those services from the PPG’s capitation, as permitted under the PPG’s contract. Health Net will provide 15 business days’ advance written notice before any deduction is made. If the PPG disagrees with the deduction, it must respond to Health Net within 15 business days from the date the notice was sent, providing an explanation of why the deduction should not occur.

Required documentation and guidelines

Requirement

Guidelines

  • Certification of terminal illness (CTI
  • Face-to-face encounter documentation (if greater than three benefit periods)
  • Medi-Cal Hospice Program Election Notice

Submit CTI, face-to-face encounter and Medi-Cal Hospice Program Election Notice (PDF), within five calendar days of certification and election of hospice care.

 

If the election form is not submitted within five calendar days, services will not be covered from the admission date to the date the completed form is received.

  • Initial care plan
  • Prior authorization
  • Written prescription

Required for inpatient care only.

  • Request for Single Case Agreement

Only allowed when medically necessary services are unavailable in network.

  • Revocation of hospice election

Required when applicable.

  • Transfer summary

 

Failure to comply

If required documentation is not submitted to Health Net within five calendar days when Health Net is at financial risk for hospice services:

  • Services will not be covered until all required documentation is received.
  • Payment will be denied to the hospice services provider.  

Additional resources and information

For more details on hospice coverage changes and document submission requirements, refer to the Hospice Services Documentation Guide (PDF), available in the Provider Library > Medi-Cal > Forms and References.

Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library on Health Net’s provider portal.

If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center at 800 675 6110.

 

This information applies to Participating Physician Groups (PPGs).

For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.

 



Last Updated: 03/04/2026