Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Home Health, Home Infusion, Hospice)
Hospice Coverage of services is subject to contract benefits and limitations.
Hospice care must be ordered in writing by a physician and
performed by a Medicare certified/JCAHO approved hospice
agency. The member must meet hospice guidelines for admission
into the program.
Services must be submitted on an 837I claim format using a
hospice contracting provider ID number or NPI. The appropriate
revenue code(s) should be submitted for the services supplied.
Hospice revenue codes are 0650-0659.
Prior authorization is required only for FEP members. Effective
April 1, 2012, hospice services require notification for all products
under MHCP to assure proper claims payment.
Rules and Regulations The authorization number provided by Blue Cross must be entered
in the REF segment on the electronic 837I.
The Provider shall have a written eligibility criteria for service
and procedures for referral to other sources that include the
following:
1. Policies shall cover all services provided by the provider
directly or under contract.
2. The policies shall define referrals accepted, admissions of
clients to provider services and the discharge of clients.
3. Criteria of eligibility for the service shall be stated clearly in
reference to such factors as: age groups, geographical area,
hours of service (including policy about 8 to 24 hour service
and weekend service), social and health needs, crises or
emergency services, referral and funding sources.
4. Eligibility criteria that apply to the service shall be available to
community professionals and organizations and persons
applying for the service.
5. There shall be a written policy for making referrals for needed
services that are not available through the provider.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
11-15