Ind. IHCP Hospice Services Provider Reference Module, Section 6, Common Hospice Explanation of Benefits Codes

The IHCP has monitored hospice claim-denial trends since the implementation of the IHCP hospice benefit.

Explanation of benefits (EOB) codes are divided into general IHCP EOB codes and IHCP hospice EOB

codes. General IHCP EOB codes appear on the remittance advice (RA) when the IHCP claim does not

meet general IHCP claim-processing guidelines. The IHCP hospice EOB codes are on the RA when a

hospice claim does not meet required IHCP hospice claim-processing guidelines.

Table 8 lists the most common EOB codes for fee-for service (FFS) hospice service denials, along with a

description of the denial EOB codes and an explanation of how the hospice provider can avoid or correct the

denial. These EOB codes are not an all-inclusive list, nor do they serve as a replacement for information

available from Customer Assistance toll-free at 800-457-4584 or on the Explanation of Benefits page at

in.gov/medicaid/providers.

Table 8 – Common EOB Codes for FFS Hospice Denials

EOB Code Description Explanation

0236 The detail line, From Date of

Service is missing. The correct

format is MMDDYY. Please

provide and resubmit.

This denial occurs when the from date of service

is missing from a detail of the UB-04 claim

form.

This denial is avoided if the provider completes

the from date of service for all details on the

claim and ensures all dates of service are legible.

0385 Member’s waiver liability is

not met for the month.

This denial occurs when the member has not

incurred enough medical expenses to satisfy the

waiver liability amount for the month. This

denial also occurs when the claim is submitted

for processing prior to the state eligibility

consultant entering the waiver liability

information into the Indiana Eligibility

Determination Services System (IEDSS).

This denial is avoided by taking the following

steps:

• Verify the recipient’s eligibility status

through one of the Eligibility

Verification System (EVS) options.

• Verify the waiver liability met date

through one of the EVS options.

If a waiver liability met date is not found

through the EVS options, verify that the client

has turned in all receipts for medical services to

the county office for calculation of waiver

liability met date and eligibility activation.

EOB Code Description Explanation

0512 Your claim was filed past the

filing time limit without

acceptable documentation.

This denial occurs when the date of service on

the claim exceeds the 180-day filing limit. The

supporting documentation was either not

included with the claim, or it does not support

efforts to bill for these services prior to the 180-day filing limit.

This denial is avoided by submitting the claim

within 180 days of the date of service. It is the

responsibility of the provider to monitor the RA

statements to ensure the claim was received and

processed. If the claim suspends, monitor the

claim until adjudication. If the claim denies, take

the necessary steps to correct and resubmit.

0513 Member’s number does not

match the member’s name.

Please verify and resubmit.

This denial occurs when the member name and

IHCP Member ID do not match.

This denial is avoided by verifying that the biller

has entered the correct Member ID for the

member.

0532 Billing provider’s specialty is

not approved to bill this

revenue code. Please verify and

resubmit.

This denial code occurs:

• If the provider is not approved to bill

hospice services

• When there is a possible duplication of

services by the hospice provider and a

home health provider.

Providers should work with an IHCP provider

field consultant to resolve this error. The field

consultant will facilitate communication with the

FFS PA-UM contractor or other appropriate

entities to resolve the EOB code.

0546 Type of bill incompatible for

service billed.

This denial occurs when incorrect revenue codes

are billed with hospice claims. To avoid this

denial, providers should bill only revenue codes

183, 551, 561, 185, 650, 651, 652, 655, 656,

657, 658 and 659 with type of bill 0813, 0819,

081A-081M, 081O, 081X-081Z or 0820-0825,

0827-0829, 082A-082K, 082M-082O, 082X-

082Z.

0563 Hospice units billed

incompatible with allowed

units for the hospice revenue

code.

This denial occurs when the units billed are not

in range for the revenue code billed.

This denial is avoided by ensuring that the

revenue code billed should have the

corresponding units billed.

Note: The Revenue Codes for Hospice

Billing table in Hospice Services

Codes (accessible from the Code Sets

page at in.gov/medicaid/providers)

provides the service units that should

be listed in field 46 of the UB-04

claim form.

EOB Code Description Explanation

0564 This revenue code is not

allowed for this member’s

eligibility.

This denial code occurs if:

• Member has Medicare Part A.

• Type of bill is 081x or 082x.

• Revenue code is 551, 561, 650, 651,

652, 655, 656, 657 or 658.

OR

• Member does not have Medicare Part

A.

• Revenue code is 659.

1035 Billing provider is not

member’s listed hospice

provider. Please verify provider

number and resubmit.

This denial occurs when the provider is not the

same provider listed in the member’s file as the

member’s authorized hospice provider for the

dates of service billed.

This denial is be avoided by verifying that the

Hospice Provider Change Request Between

Indiana Hospice Providers form (State Form

48733 [R/12-02] OMPP 0009) has been

completed and submitted to the FFS PA-UM

contractor.

Note: This denial has also occurred when

hospice providers have used the

incorrect hospice provider number

from another hospice office location

within Indiana or a hospice agency in

another state that does not

correspond to the hospice provider

number listed on the hospice

authorization form.

2003 Member not eligible for Indiana

Health Coverage Program

benefits for dates of service.

This denial occurs when the member was not

eligible for benefits at the time the service was

provided.

This denial is avoided by verifying eligibility

prior to the provision of any services.

Note: It is recommended that providers

check eligibility on the 1st or 15th of

the month or at least monthly using

one of the IHCP EVS options and

document the eligibility information

in the patient’s file.

EOB Code Description Explanation

2008 Member not eligible for this

level of care for dates of

service.

This denial occurs when the member does not

have a hospice level of care on file for the dates

of service billed.

This denial is avoided by doing the following:

• Bill only after receiving approval for

the certification period from the FFS

PA-UM contractor.

• Contact the FFS PA-UM contractor to

verify that the initial election or

recertification paperwork has been

received and processed. Contact the

FFS PA-UM contractor no sooner than

14 business days after having mailed

the paperwork.

2026 Member not eligible for the

level of care for the dates of

service and revenue codes

billed.

This denial occurs when a hospice recipient is

billing revenue codes 650, 658, 659, 183 or 185,

but a nursing facility level of care is missing or

not active for the dates of service being billed.

This denial is avoided by ensuring that the

appropriate authorization has been obtained via

the Preadmission Screening and Resident

Review (PASRR) process.

4040 The primary diagnosis code is

not a valid diagnosis code.

Please verify and resubmit.

This denial occurs when hospice services are

billed and the primary diagnosis code is not on

the diagnosis table for type of bill 0813, 0819,

081A-081M, 081O, 081X-081Z or 0820-0825,

0827-0829, 082A-082K, 082M-082O, 082X-

082Z.

This denial is avoided by checking that the

primary hospice diagnosis is in field 67 of the

UB-04 claim form.

4215 Leave days not a covered

service for this bill type –

nursing facility occupancy less

than 90%

This denial occurs when hospice services are

billed using revenue code 180 for a dually

eligible member residing in a nursing facility.

This denial is avoided by billing claims for these

members using revenue code 659.

EOB Code Description Explanation

4233 Date of death/discharge is not

covered.

This denial occurs when a date of

death/discharge occurrence code is not used.

CoreMMIS calculates the bill twice: first for the

long-term care (LTC) portion and second for the

hospice portion. The code is set up to deduct

patient liability and apply it to the LTC portion

of the bill which is paid first, by design.

Consequently, there is no balance left for patient

liability. CoreMMIS does not apply patient

liability to the routine home hospice care portion

of the claim; however, third-party liability (TPL)

is applied.

If a date of death/discharge occurrence code is

used for the date of death/discharge, the hospice

portion of the claim is paid.

Occurrence code 51 is used for live discharge.

4340 Incomplete billing information

for hospice SIA revenue codes

551/561. Revenue codes

551/561 require revenue codes

651 or 650 (653 thru

12/31/2018) on same DOS,

plus occurrence code 55 and

member’s date of death, and

patient discharge status 20, 40,

41, or 42.

This denial occurs when SIA revenue codes 551

or 561 are not reported with all the following:

• Revenue codes 651 or 650 on the same

dates of service on the same claim

• Occurrence code of 55 with the

member’s date of death in the first

available occurrence code field on the

UB-04 claim form

• Patient discharge status of 20, 40, 41 or

42

4341 DOS must be no more than

7 days prior to the date of

death.

This denial occurs when the SIA revenue codes

551 or 561 are billed for dates of service within

seven or more days prior to the date of death.

5001 This is a duplicate of another

claim.

This denial occurs when the claim being

processed is an exact duplicate of a claim on the

history file or another claim being processed in

the same cycle.

This denial is avoided by verifying previous

claim denial by using the virtual assistant

(GABBY) at 800-457-4584 or the IHCP Portal

to verify previous claim payment to another

provider.

If a spend-down met date is not found through

the EVS, verify that the client has turned in all

receipts for medical services to the county office

for calculation of spend-down met date and

eligibility activation.