OA-B9: Patient Enrolled in Hospice

What Does OA-B9 Mean?

OA-B9 appears in coordination of benefits scenarios involving hospice patients where the financial responsibility for the denial is not clearly assignable to the provider or the patient. This typically occurs when a secondary payer processes a claim for a hospice patient and the hospice coverage determination crosses payer boundaries.

CARC B9 fires when the payer identifies the patient as having an active hospice election and determines that the billed service falls within the scope of their hospice care. Under Medicare rules, once a patient elects hospice, the hospice organization assumes responsibility for virtually all care related to the terminal illness. Any provider outside the hospice who bills separately for services connected to the terminal condition will receive a B9 denial because those services are already covered under the hospice per diem payment.

The critical distinction with B9 is whether the billed service is related or unrelated to the patient's terminal diagnosis. Services unrelated to the terminal condition — such as treating a fracture in a patient whose hospice diagnosis is lung cancer — can be billed separately and are covered under standard Medicare Part B. However, the provider must clearly indicate the unrelated nature of the service by appending modifier GW (service not related to the hospice patient's terminal condition) to the claim. Similarly, attending physician services not provided by a hospice-employed physician require modifier GV.

B9 typically appears with Group Code CO because the denial is based on coverage rules, not patient behavior. The provider cannot bill the patient for services that should have been covered under hospice. Resolution requires careful clinical determination: if the service truly was related to the terminal condition, the denial is correct and the hospice provider is the appropriate billing entity. If the service was unrelated, adding the correct modifier and resubmitting with supporting documentation should resolve the claim.

Common Causes

How to Resolve

Confirm the patient's hospice status, classify the service as related or unrelated to the terminal condition, and resubmit with the appropriate modifier if unrelated.

1. Identify the COB arrangement Determine the payer hierarchy and confirm which payer covers the hospice benefit versus which covers non-hospice services.
2. Redirect if necessary If the service is unrelated to hospice, resubmit to the appropriate payer with modifier GW. If the hospice benefit is with a different payer, redirect the claim accordingly.

Common RARC Pairings

The RARC code tells you exactly what triggered the OA-B9:

How to Prevent OA-B9

• Verify hospice coverage with all payers in the patient's coverage chain before rendering services
• Understand which payer holds the hospice benefit to avoid misdirected claims

General Prevention

• Confirm hospice enrollment status before rendering services by checking eligibility systems or contacting the payer
• Train clinical and billing staff on Medicare Part A and Part B hospice coverage distinctions
• Apply correct modifiers (GV for attending physician services, GW for unrelated services) consistently on all claims for hospice patients
• Maintain comprehensive clinical documentation that clearly distinguishes services related to the terminal condition from unrelated services
• Coordinate with the patient's hospice provider to understand the hospice plan of care and avoid billing conflicts
• Implement eligibility verification workflows that flag patients with active hospice elections

Also Filed As

The same CARC B9 may appear with different Group Codes:

Related Denial Codes