Billing and Reimbursement

Who is responsible for paying R&B for dually eligible Medi-Cal members (i.e., Medicare is primary and Medi-Cal is secondary)?

When a dual-eligible Member residing in a Skilled Nursing Facility (SNF), Nursing Facility (NF), or Intermediate Care Facility (ICF) elects hospice under Medicare, Medicare remains the primary payer for the Member’s hospice services. The MCP remains responsible for the separate Medi-Cal room and board payment. The Medi-Cal room and board payment is a distinct payment obligation. The MCP does not assign or approve the Member’s Medicare hospice Provider. The MCP’s Medi-Cal room and board payment responsibility does not provide MCPs subcontractors authority to redirect the Member to a Network hospice Provider, nor make payment contingent upon a Member using a Network hospice Provider. MCP timely payment for room and board must be made directly to the hospice Provider for dually eligible SNF/NF or ICF residents. MCPs cannot require authorization for the hospice Provider to bill the MCP for the room and board covered by Medi-Cal while the dual-eligible Member is receiving hospice services under Medicare. Additionally, MCPs cannot require a copy of an Explanation of Benefits, Remittance Advice, or denial letter from Medicare to accompany room and board claims. MCPs may verify information reasonably necessary to establish Medi-Cal room and board payment responsibility, but not in a manner as to require unwarranted or excessive information or clinical approval requirement.

Medi-Cal MCPs are denying R&B for lack of authorization or because the hospice provider is out-of-network. What can hospice providers do?

In regard to Medi-Cal only Members, MCPs cannot require authorization as a condition of payment for room and board for Members receiving hospice services and residing in a SNF/NF or ICF. MCPs cannot separately and solely deny room and board claims for Members that have a valid hospice election and have been authorized hospice care, whether in-Network or out-of-Network, as such payment denial could be seen as a disruption of the regulatory written agreement relationship between the hospice Provider and the SNF/NF or ICF facility, since it interferes with the hospice Provider’s obligation and ability to pay room and board to the SNF/NF or ICF facility.

Hospice providers should utilize the appeals process with the MCP. Providers can file a provider complaint with the Department of Managed Health Care (DMHC) if the MCP is not a County Organized Health System (COHS) plan. Ultimately, providers can engage in the provider dispute resolution process with the MCP.

Can Medi-Cal R&B claims be denied for dually eligible members?

No. Medi-Cal cannot deny R&B claims for dually eligible Medi-Cal members receiving hospice services. DHCS clarified this requirement in APL25-008, as well as subsequent policy clarification guidance on July 27, 2026,  which instructs Medi-Cal MCPs to pay R&B claims as a mandatory pass‑through payment for dually eligible Medi-Cal members who are residing in Skilled Nursing Facilities and receiving hospice care. The APL also confirms that Medi-Cal MCPs may not require prior authorization and must make these payments whether or not the hospice provider is in network.

Should R&B claims be billed to DHCS or the Medi-Cal MCP?

Hospice providers must submit R&B claims to DHCS for Medi-Cal FFS members and the respective MCP for Medi-Cal managed care members, depending on eligibility.

What happens with retroactive eligibility?

There are some limited circumstances beyond the control of hospice providers where it may not be possible to timely file a Medi-Cal Hospice Program Attestation Form with DHCS within the five calendar days of Medi-Cal FFS members’ hospice election—retroactive eligibility is one of those circumstances. When retroactive eligibility is confirmed, DHCS may consider the attestation timely and allow reimbursement for hospice services beginning from the member’s effective eligibility date, so long as all other Medi-Cal coverage, billing, and documentation requirements have been met, which includes but is not limited to the following:

• The hospice provider was not and could not have been reasonably aware that the Medi-Cal FFS member was eligible for hospice services at the time of election, and can provide documentation of the following:
  • Proof of retroactive eligibility
  • A submitted and approved Medi-Cal Hospice Program Attestation Form
  • A CTI

Will Medi-Cal MCPs follow Medi-Cal’s updated hospice coverage and billing policy, including utilization management controls, TAR requirements, and periods of care?

Medi-Cal MCPs must offer the same benefit package as Medi-Cal FFS from a coverage perspective; however, as part of the upcoming updates to coverage and billing policy in both the Medi-Cal Provider Manual and APL, Medi-Cal MCPs may choose but are not required to implement prior authorization (PA; equivalent to a Medi-Cal FFS TAR requirement) as a component of their utilization management controls for the four levels of hospice care.

Does Medi-Cal’s updated coverage and billing policy, including utilization management controls/TAR requirements, apply to D-SNP Medicare/Medi-Cal duals?

Dual eligible rules in APL 25-008 apply. MCPs cannot require PA for Medi-Cal R&B for Medicare hospice cases.

What happens if claims for hospice services are denied for “no eligibility”?

Hospice providers are responsible for confirming Medi-Cal eligibility for the individuals they serve prior to rendering services. Failure to do so may result in claim denials and provider liability for the hospice services. However, if a hospice provider believes a claim denial received for “no eligibility” is erroneous, the hospice provider should follow the above listed steps to appeal the denied claim.

Is there a limit to the number of hospice agencies a physician may serve as Medical Director?

Medi-Cal policy does not dictate any such requirement. Similarly, Medicare rules do not specify a limit (see 42 CFR Part 418). However, hospice agencies are independently responsible for ensuring compliance with any applicable state and/or federal oversight requirements, and both Medicare and DHCS may audit providers at any time to ensure compliance.

Are TARs required when hospice is billed to Medicare but Medi-Cal is billed only for Room & Board (R&B)?

No. TARs will not be applied to  R&B. While updated utilization management controls will apply to all hospice levels of care, R&B is excluded from TAR/PA requirements.

Are TARs required for dually eligible Medi-Cal members (i.e., Medicare (primary) and Medi-Cal (secondary))?

Yes. If Medi-Cal is billed for any hospice services, a TAR will be required as specified in the updated coverage and billing policy.

When do TAR requirements for hospice services begin?

For Fee-For-Service (FFS), the Department of Health Care Services (DHCS) anticipates release of the updated coverage and billing policy through the provider manual, sometime in late 2026 or early 2027, which will outline all utilization management controls, including TAR requirements. For managed care, the updated APL is anticipated for release later in 2026.

Are TARs still only required for General Inpatient Care (GIP) level of care?

No.  Upon implementation of the updated coverage and billing policy, TARs will apply to all hospice levels of care, including GIP, as specified.

Will TARs be required for R&B or Skilled Nursing Facility (SNF) room & board?

No. R&B will not require a TAR.

When are TARs required under Medi-Cal’s updated periods of care?

 The Medi-Cal periods of care will be defined in policy, including when a TAR must be submitted.

Do TARs need to be approved before submitting the next TAR?

No. Each TAR is tied to a specific periods of care. A new TAR may be submitted even if the previous period of care’s TAR is still pending; however, DHCS encourages hospice providers to submit TARs timely to ensure processing can occur timely.

Does a TAR ending mid-month stop payment?

Claims will only be reimbursed for dates of services (DOS) corresponding to the approved TAR’s period of care. Claims with DOS outside of the approved TAR period of care may be denied.

Does documentation, Certification of Terminal Illness (CTI), and Plan of Care (POC) need to match approved TAR for the period of care?

Yes. The CTI and POC must align with each period of care and approved TAR. The provider manual will provide direction on what must be submitted with the TAR.

What is the ‘900 code’ and why is it important? 

The 900 code is a unique indicator added to the Medi-Cal billing system after DHCS receives a valid Hospice Program Attestation form. Claims will be denied without this code.

How does Hospice Program Attestation Form submission impact reimbursement? 

No form = No 900 Code = No Payment. Late or missing forms result in denied claims.

What happens if I miss the five-day submission deadline? 

Late submissions are non-compliant and result in reimbursement only from the date the form is received.

What If the Hospice Election or Addendum forms are rejected?         

The Hospice Clerk will notify the Hospice agency of the necessary corrections as soon as possible. 

Where can I find the DHCS Hospice Program contact information?           

The DHCS Hospice Program web page has contacts, resources, and the latest updates. You can email your questions to MCHospiceClerk@DHCS.ca.gov or call (916) 552-9200.

What is the “5-Day Rule” for the attestation submission?

Hospice providers must submit the Attestation Form within five (5) calendar days of the member’s hospice election date:

• For FFS members: DHCS must receive the form within 5 days.
• For MC members: The MCP must receive the form within 5 days.

Late submissions are non-compliant and result in:

• Potential denial of payment for days before receipt.
• Reimbursement only from the date the form is received

Are there exceptions to the 5-day rule?

Yes. DHCS may allow exceptions in limited cases, such as:

• Natural disasters or emergencies: This includes fires, floods, earthquakes, or other events that disrupt operations.
• System or technical failures: DHCS system outages or email delivery failures that prevent timely submission.
• Newly certified hospice providers: DHCS system access not yet granted and/or delay in onboarding after certification.
• Retroactive Medi-Cal Eligibility: Hospice provider was not and could not have been reasonably aware that the Medi-Cal member was eligible for hospice services at the time of election. For this item, hospice providers must document and provide: Proof of retroactive eligibility;Valid hospice Attestation form;Certification of terminal illness; andAdministrative corrections, if any.

For any of the above exceptions, please note that DHCS will only accept late attestation forms when the delay is beyond the hospice provider’s control and the hospice provider’s actions or inactions did not otherwise contribute to or result in the delay. Absent an approved exception from DHCS, hospice services rendered under a late Medi-Cal Hospice Attestation form will not be eligible for any reimbursement. 

How do I know whether to send the form to DHCS or an MCP?

Check the member’s eligibility on the hospice election date using:

• MEDS (Medi-Cal Eligibility Data System)
• POS (Point of Service) system

Also check for retroactive MCP enrollment to avoid misrouting.

Does this new process apply to both Medi-Cal fee-for-service (FFS) and managed care members?

No. This new process only applies to Medi-Cal FFS members electing to receive hospice services.

Are NOEs required for dual-eligible Medi-Cal members?

Yes. Even if Medi-Cal is the secondary payer and Medicare is primary, a valid hospice NOE form is required to be on file for all Medi-Cal members (both FFS and managed care) electing to receive hospice services.

Do hospice providers need to submit a hospice Attestation Form for a dual-eligible Medicare/Medi-Cal member for which the hospice provider is only submitting room & board claims to DHCS or a Medi-Cal MCP for payment?

Yes. A valid hospice Attestation Form must be submitted and on file in order for DHCS or a Medi-Cal MCP to reimburse hospice providers for room and board claims.

What if the individual does not have Medi-Cal at admission but is approved retroactively?

Hospice providers are responsible for verifying Medi-Cal member eligibility prior to rendering and billing for hospice services. Additionally, hospice providers can contact the DHCS Hospice Clerk for further assistance at MCHospiceClerk@dhcs.ca.gov. Hospice providers will need to provide proof of retroactive eligibility and submit the Attestation Form within five (5) days of the Medi-Cal member’s election date.

How do hospice providers notify DHCS of a Medi-Cal member revocation of hospice services?

Hospice providers must submit notice of revocation for Medi-Cal FFS members only via email directly to the DHCS Hospice Clerk at MCHospiceClerk@dhcs.ca.gov. For Medi-Cal managed care members, hospice providers must submit that information directly to the Medi-Cal member’s assigned MCP. Please note that this is the current process.

Do hospice providers also need to notify DHCS regarding discharges and/or transfers?

Yes. Hospice providers must timely notify DHCS for Medi-Cal FFS members, or the assigned Medi-Cal MCP for Medi-Cal managed care members, relative to all discharges and/or transfers as well as the reason for the discharge and/or transfer (e.g., death or moving out of service area, etc.).

What if the Medi-Cal member revokes and later returns to hospice, do hospice providers need to submit a new hospice Attestation Form?

Yes, a new hospice Attestation Form must be submitted and on file if the Medi-Cal member revokes hospice but then later returns to hospice.

What if the Medi-Cal member transfers from another hospice, do hospice providers need to submit a new hospice Attestation Form?

Yes, a new hospice Attestation Form must be submitted and on file if the Medi-Cal member transfers from one hospice provider to another.

What if the Medi-Cal member does not have a diagnosis of a terminal illness at admission?

A physician’s certification of terminal illness is required before the hospice provider submits the hospice Attestation Form.

Is a placeholder diagnosis code acceptable?

No. A valid diagnosis code and physician’s certification of terminal illness is required.