MedicaidCoverageHigh impact
Provider Notification - Notification of Hospice Claim Recoupments & Implementation of Processing Edits
Aetna Better Health of Virginia·VA · Palliative Care, Geriatrics·Reimbursement
We identified it
Aug 13, 2026
Summary
Aetna Better Health of Virginia is implementing claims processing edits to prevent billing of hospice-related services, DME, and nursing facility room and board that are already included in hospice per-diem rates or require appropriate waivers. The payer will retroactively recoup claims paid in error within the last 365 days and deny future claims that violate these bundling rules using specific CARC/RARC denial codes.
Action Required
IMMEDIATE: Billing team must implement the following changes: (1) Review all claims submitted to Aetna Better Health of Virginia for hospice members within the last 365 days to identify potential recoupments—focus on DME, medical supplies, comfort items, and nursing facility room and board charges. (2) Audit billing processes to prevent billing DME, medical supplies, and comfort items related to terminal illness when members are enrolled in hospice; these services must be coordinated with and billed through the hospice provider. (3) Verify waiver status before submitting nursing facility room and board claims; recoupments will occur when members have only a hospice waiver (no NF waiver). (4) Update billing system edits to bundle and deny claims that include services in the hospice per-diem or trigger CARC 97, 252, B13 with RARC M15, N188, or M97. (5) Train all billing staff and providers on the bundling rules outlined in the Hospice Provider Manual (Chapter IV, 8/28/2024 revision) and DME Manual (Chapter IV, 12/5/2025 revision). Failure to comply will result in claim denials and financial recoupments. Expect to see these denial codes on remittance advices once the edits go live.