How to appeal an Elevance Health hospice / palliative — eligibility, gip, recertification, concurrent care denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

Elevance Health-specific note: Operates Anthem BCBS in 14 states. Owns Carelon (formerly AIM) which manages utilization for specialty drugs and advanced imaging. State complaint route is to the state insurance department where the policy was issued.

What Elevance Health's policy requires for hospice / palliative — eligibility, gip, recertification, concurrent care

Cited policy: Anthem / BCBS Concurrent Care for Children — Medicaid managed care plans must cover per ACA §2302 (42 USC §1396d(o)(1)); commercial plans increasingly follow voluntarily

Child under 21 enrolled in Medicaid or CHIP may receive disease-directed (curative) treatment AND hospice services concurrently; documentation of both regimens; election of hospice benefit by parent/guardian.

How Elevance Health denies hospice / palliative — eligibility, gip, recertification, concurrent care — and how to counter it

Where Elevance Health pushes back: 1) 'Curative care excludes hospice election'; 2) 'Hospice + curative considered duplicative'; 3) 'ACA §2302 not applicable to this plan'; 4) 'Concurrent care provider not in-network'.

Counter-arguments that hold up: Cite ACA §2302 (Affordable Care Act Section 2302), codified at 42 USC §1396d(o)(1). Cite CMS Informational Bulletin (CIB) on Concurrent Care for Children Requirement (Sept 2010 + subsequent updates). Cite NHPCO Pediatric Hospice and Palliative Care Standards. Document patient age <21, Medicaid/CHIP enrollment, curative regimen (oncologic protocol, transplant, etc.), and hospice election. For commercial plans cite voluntary alignment with concurrent-care policy and AAP Section on Hospice and Palliative Medicine position.

What Elevance Health typically denies for hospice / palliative — eligibility, gip, recertification, concurrent care

Across Elevance Health's commercial and Medicare books, denials cluster around a small number of patterns. For hospice / palliative — eligibility, gip, recertification, concurrent care, expect:

• Step therapy
• Medical necessity for biologics
• Out-of-network for behavioral health
• Bariatric surgery prior auth

Treatments most often denied in this category

These are the hospice / palliative — eligibility, gip, recertification, concurrent care treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Hospice eligibility
• Hospice recertification
• Hospice GIP
• Hospice CHC
• Hospice respite
• Hospice routine

How to submit the appeal to Elevance Health

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Elevance Health cited in the denial.
3. File the appeal through Elevance Health's portal (members: https://www.anthem.com ; providers: https://providers.anthem.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In IN, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Elevance Health's prior-authorization criteria by drug: Elevance Health PA criteria on ApprovalHelp.