Medicare AdvantageReimbursementHigh impact
23-578 Bill Medicare for Claims for Dual Coverage Members Enrolled in Hospice
Health Net·CA · Palliative Care·Prior Authorization
Effective date
Sep 1, 2023
We identified it
Jun 20, 2026
Summary
Health Net will recoup previously paid hospice claims for dual coverage members enrolled in Medicare hospice benefits, effective September 1, 2023. Providers must bill Medicare directly for hospice services and will receive recoupment notices for inappropriately paid claims that should have been submitted to CMS instead.
Action Required
Immediately: Billing team must identify all dual coverage members with Medicare hospice benefits and bill Medicare (CMS) directly for hospice claims instead of Health Net. Update billing workflows to verify Medicare hospice enrollment before submitting claims. Monitor for recoupment notices from Health Net and resubmit affected claims to CMS for reimbursement. Exclude Medicare Part D, supplemental services, modifier GW, condition code 07, and procedure codes S5170/S5161 from this change.