Quick Explanation
Denial code HP5 indicates that a medical claim was rejected because the patient is actively pursuing curative treatment, which conflicts with their hospice benefit status. Under Medicare and major commercial payer guidelines, electing hospice care requires the patient to waive curative treatments for their terminal illness. Consequently, billing for non-palliative, curative therapies or procedures during an active hospice enrollment period results in this denial.
Common Causes for HP5
Denials with code HP5 typically happen for the following specific reasons:
- Billing for curative therapies such as chemotherapy, radiation, or invasive surgeries designed to treat the terminal diagnosis after the patient has elected hospice care.
- Failure of the provider to submit a formal hospice revocation form to the payer before initiating curative medical treatments.
- An external, non-hospice physician billing for treatments related to the terminal illness without utilizing the appropriate modifier to denote unrelated care.
- Lack of communication or coordination between the hospice interdisciplinary group and external specialists, leading to overlapping curative and palliative treatment claims.
How to Prevent HP5 Denials
To avoid receiving this denial in the future, implement these specific checks:
- Perform real-time eligibility checks prior to rendering services to verify the patient's active hospice enrollment status.
- Ensure that a signed hospice revocation or discharge form is successfully processed by the payer before scheduling or billing for curative interventions.
- Apply appropriate modifier codes, such as Modifier GW (service unrelated to the hospice terminal condition) or Modifier GV (attending physician not employed by the hospice), when services are clinically independent of the hospice diagnosis.
- Establish clear protocols for clinical staff to document and differentiate between palliative care measures and active curative treatments in the patient's medical record.
Appeal Letter Template for HP5
If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.
[Your Practice Header]
[Date]
[Payer Name]
[Appeals Department Address]
RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: HP5 - Patient pursuing curative treatment
Dear Appeals Department,
I am writing to appeal the denial of the above-referenced claim, which was denied with code HP5: "Patient pursuing curative treatment".
We are formally appealing the denial of the enclosed claim under code HP5 (Patient pursuing curative treatment). Pursuant to the CMS Medicare Benefit Policy Manual, Chapter 9, a beneficiary who has elected hospice benefits waives the right to Medicare payment for services related to the treatment of the terminal condition for which hospice care was elected, or a related condition. However, services that are clinically unrelated to the terminal diagnosis remain fully coverable under standard medical benefits. In this case, the medical records demonstrate that the services rendered on the disputed date of service were directed toward treating an entirely unrelated, acute condition rather than the patient's terminal illness. Because these services were not curative treatments for the hospice-defining diagnosis, they are eligible for reimbursement, and we respectfully request that this denial be overturned and the claim be processed for payment.
Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].
We respectfully request that you reprocess this claim for payment.
Sincerely,
[Your Name]
[Title]
[Practice Name]
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