SIA Eligibility Criteria

SIA eligibility criteria are the specific conditions a hospice visit must meet to generate a Service Intensity Add-on payment. All four must hold: the day is a Routine Home Care day, it falls in the last seven days of life, the visit is by an RN or medical social worker, and the visit time is recorded in qualifying units.

Each condition is checked against the claim. First, the level of care on the date of service must be RHC; SIA never pays on Continuous Home Care, General Inpatient Care, or Inpatient Respite Care days (CMS FY2016 final rule)^[1]. Second, the date must fall within the seven-day window ending on the date of death, which is why SIA is adjudicated retrospectively. Third, the visit must be delivered in person by a registered nurse or a medical social worker; LPN/LVN, aide, and chaplain time does not qualify, and social worker phone calls are specifically excluded (Medicare Claims Processing Manual, Ch. 11, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c11.pdf). Fourth, visit time is billed in 15-minute units, from a minimum of one unit up to a combined maximum of 16 units (four hours) of nursing and social work time per day, paid at the Continuous Home Care hourly rate of $69.76 for FY2026 (CMS FY2026 final rule fact sheet)^[2].

The most common source of missed SIA is documentation, not eligibility. A claim cannot substantiate SIA units if visit start and stop times or discipline are absent from the visit record, even when the care was delivered. Because eligibility depends on the date of death, SIA is confirmed retrospectively — the final claim is where the seven-day window crystallizes and eligibility is established or forfeited. A level-of-care transition to GIP or CHC in the final days terminates SIA eligibility for those days; transitions near death therefore carry a direct revenue consequence alongside their clinical rationale.