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26-290 Support Timely Outpatient Hospice Care Admissions and Reimbursement

Date: 03/05/26

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

When Health Net, on behalf of CalViva Health, 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 the Plan within five calendar days.

What you need to do

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

  1. Submit complete hospice documentation directly to the Plan (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 the Plan, you must redirect the member to a participating hospice provider.

PPG-issued prior authorizations when the Plan has financial risk

If a PPG issues prior authorization for Medi-Cal outpatient hospice services for which the Plan is at financial risk, the Plan may deduct the cost of those services from the PPG’s capitation, as permitted under the PPG contract. The Plan will provide 15 business days’ advance written notice before any deduction is made. If the PPG disagrees with the deduction, it must respond to the Plan 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 the Plan within five calendar days when the Plan 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 the 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 the provider portal.

If you have questions regarding the information contained in this update, contact CalViva Health at
888-893-1569.

 

This information applies to Participating Physician Groups (PPGs).

This information applies to Medi-Cal in Fresno, Kings and Madera counties.



Last Updated: 03/04/2026