Medi-Cal Provider Manual, Part 2, Hospice Care: General Billing Instructions, Treatment Authorization Request: General Inpatient Care (Revenue Code 0656)

General inpatient care (revenue code 0656 billed in conjunction with HCPCS code T2045)

requires the submission of a Treatment Authorization Request (TAR). General inpatient care

during the first 90-day hospice election period may be approved if the TAR is received with

all of the required documents listed below:

• Written prescription signed by the recipient’s attending physician

• Patient’s Hospice Election form

• Initial written plan of care

• Certification of terminal illness by a physician

• A Hospice General Inpatient Information Sheet (DHS 6194) and documentation

specified in the Manual of Criteria for Medi-Cal Authorization, Chapter 11, “Criteria for

Hospice Care,” Section IV

For providers rendering services during second 90-day or subsequent 60-day periods, a

TAR may be approved upon receipt of a document which recertifies the recipient’s terminal

illness and is signed by a hospice physician.

Fax TAR and Hospice General Inpatient Information Sheet

For concurrent authorization via the fax TAR (form 50-2) process, contact the TAR

Processing Center (refer to the TAR Overview section in the Part 1 manual). The Hospice

General Inpatient Information Sheet (DHS 6194) must be attached to fax TARs. For

information about the DHS 6194, refer to the Hospice Care: General Inpatient Information

Sheet section of this manual.

Providers must keep copies of documentation previously sent with the TAR (for example,

physician’s certification of terminal illness, copy of the plan of care and election statement).

‹‹Hospice Program Election Notice (DHCS 8052) and Patient Notification

of Hospice Non-Covered Items, Services, and Drugs (DHCS 8053) Forms

The Medi-Cal Hospice Program Election Notice (DHCS 8052) and Patient Notification of

Hospice Non-Covered Items, Services, and Drugs (DHCS 8053) forms are required for all

licensed and certified hospice agencies to use initially when Medi-Cal eligible individuals

elect Hospice services. See the New Hospice Election Notice and Addendum Forms section

of the Hospice Care provider manual section for further information and provider instruction.

Additional information and access to the forms may be found at the Hospice Care page of

the DHCS website.››