Ga. Medicaid Part II Policies & Procedures for Hospice Services § 601

A hospice is a public agency or private organization or a subdivision of either that is primarily

engaged in providing care to terminally ill individuals. Hospice services are forms of palliative

medical care designed to meet the physical, social, psychological, emotional, and spiritual needs of

terminally ill individuals and their families.

The focus of hospice services is palliative care rather than curative care for adults. Effective

03/23/2010, children will no longer be required to forego curative care when electing hospice. These

children may concurrently receive palliative and curative treatment. This new concurrent care

provision enables States to make hospice services available to children eligible for Medicaid and

Medicaid expansion CHIP programs without forgoing any other treatment to which the child is

entitled under Medicaid. Concurrent care does not change the criteria for hospice services eligibility,

policies, procedures or responsibilities hospice providers have in providing services to the terminally

ill child. Hospice services and supports to children continue to include pain and symptom

management and family counseling provided by specialty-trained hospice staff. (Rev. 07/2015)

Individuals may elect to receive hospice care during one or more of the following election periods

that require written certification by the physician, Election periods are as follows: two (2) initial

periods of ninety (90) days each, and an unlimited number of subsequent sixty (60) day periods each.

Benefit periods can be used consecutively or at different times during the individual’s life span. Each

benefit period requires a physician to certify at the beginning of the period that the individual has a

terminal illness with a prognosis that the individual’s life expectancy is six (6) months or less if the

illness runs its normal course. A single election remains in effect through physician certified periods

if the individual does not revoke or discharge out of hospice.

The certification of terminal illness of an individual who elects hospice shall be based on the

physician’s or medical director’s clinical judgment regarding the normal course of the individual’s

illness while understanding that making medical prognostication of life expectancy is not always

exact. The certification must remain on the individual’s file.

In addition to the general conditions of participation identified in Section 106 of the Part I Policies

and Procedures manual, providers in the Hospice Services Program must meet the following

conditions:

601.1. Licensure and Certification

601.1.1. The hospice agency must be currently licensed under the provision of

State law and must not be operated primarily for the care and treatment

of patients with mental disease or special disorders.

601.1.2. The hospice agency must meet Title XVIII Standards for Medicare

participation as currently determined and be certified as eligible for

participation.

601.1.3. The hospice agency must develop written policies and procedures on

advance directives in compliance with Section 1902 (a) (57) of the Social

Security Act.

601.1.4. In compliance with Section 1902 (a) (57) of the Social Security Act, the

hospice agency must:

601.1.5. Provide written information to individuals regarding their rights under

state law to make decisions concerning their medical care, including the

right to accept or refuse medical or surgical treatment and the right to

formulate advance directives.

601.1.6. Provide written information to individuals regarding the institutions or

program’s written policies respecting the implementation of the right to

formulate advance directives.

601.1.7. Document in the individual’s medical record if an advance directive has

been executed.

601.1.8. Comply with all requirements of State law respecting advance directives.

601.1.9. Provide (individually or with others) education for staff and the

community on issues concerning advance directives.

601.1.10. Not condition the provision of care or otherwise discriminate against an

individual who has executed an advance directive.

601.2. Provider Enrollment Application

Copies of the following documents must be submitted with the enrollment application:

601.2.1. A letter from the State licensing unit showing the permit number and

effective date of permit.

601.2.2. A document from the State licensing unit showing that the hospice has

been recommended for certification or that it meets the requirements for

the Medicare program.

601.2.3. A copy of the written notification to the hospice from the Medicare fiscal

intermediary showing the approved reimbursement rate, the fiscal year

end, and Medicare provider number.

601.2.4. Advance Directives Letter of Agreement (See Appendix H).

601.2.5. A copy of the letter from the Office of Civil Rights indicating services

are provided in compliance with Title VI of the Civil Rights Acts of

1964.

601.2.6. A copy of the completed Office of Regulatory Services (ORS)

Ownership Disclosure Form.

The information requested above should be submitted in one packet

along with a completed DMA Statement of Participation. Gainwell

Technologies Enterprise Services post office box is closed effective May

1, 2015.

Gainwell Technologies Enterprise Services will no longer receive

Provider Enrollment paper documents via the US mail. All supporting

Provider Enrollment documentation should be uploaded via the

GAMMIS web portal to pending applications. Please refer to the Part I

Policy and Procedures Manual for Medicaid and PeachCare for Children,

Chapter 100, Section 112. If you need to submit updated documentation,

please fax it to Gainwell Technologies Provider Enrollment at 1-866-

483-1045. All faxes must be accompanied with a Gainwell Technologies

Provider Enrollment fax cover sheet. The form can be found under

>Provider Enrollment>Forms.

601.3. Agency Responsibilities

601.3.1. The hospice agency must maintain current medical records on all

individuals as described in Section 908. All hospice forms (Includes the

Election, Revocation, Discharge, Transfer, Hospice Care Communicator

(HCC), certifications and a copy of the nursing facility (NF) DMA-59’s

when applicable) must be completed and in the individual’s medical

record at the hospice agency.

601.3.2. All Medicaid forms submitted to the Division after receipt of the new

provider number must be incompliance with Part I Policies and

Procedures Manual applicable to all Medicaid providers and with Part II

Policies and Procedures for Hospice Services Manual.

601.3.2.1. This includes maintaining such written records for

Medicaid/PeachCare for Kids members as necessary to

disclose fully the extent of services provided and the

medical necessity for the provision of such services, for

a minimum of five (5) years after the date of service.

Active and recently active records must be maintained at

the approved service location for review for a minimum

of (2) two years after the last date of service.

601.3.2.2. Comply in a timely fashion with all requests for records,

information, and documentation made by the Division,

its authorized representatives and agents, and the

Secretary of the U.S. Department of Health and Human

Services, related to services provided under the

Medicaid/PeachCare for Kids Program. Records,

information, and documentation requested during onsite

visits must be made available within two (2) hours of the

request to be considered timely. Records requested by

mail must be made available within 14 days of the date

of the request letter to be considered timely. Records not

received in a timely fashion may be subject to

recoupment for the services which are the subject of the

audit.

601.3.3. All claims submitted to the Division after receipt of the new provider

number must be compliant with Part I Policies and Procedures Manual

applicable to all Medicaid providers.

601.3.4. All member forms (except claims) for persons who were served between

the submission date of the enrollment packet and the effective date of

enrollment must be received by Gainwell Technologies Enterprise

Services within thirty (30) days of the date of the provider enrollment

letter from the Division. A copy of the Provider Enrollment letter

indicating the new provider number effective date must be attached to

each hospice form.

601.3.5. If the forms are received after the thirty (30) day timeframe, the effective

date of the election will be amended to the date of receipt by the

Division.

601.3.6. The hospice agency is responsible for ensuring that all services furnished

to individuals are provided in a safe and effective manner by qualified

personnel and in accordance with a written Plan of Care.

601.3.7. Hospice agencies, which provide services under contract or subcontract

with individuals or other companies, must maintain copies of such

contractual agreements in the agency file. Such agreements must specify

which hospice services are being subcontracted and must specify that the

Medicaid enrolled hospice agency retains administrative and supervisory

responsibility for staff and service subcontracted. The hospice is

responsible for the payment of hospice staff services that have been

provided under a contractual arrangement, or any applicable nursing

facility charges. Copies may be requested by the Division at any time as

needed.

601.3.8. Hospice agencies entering into agreements with nursing facilities to

provide services to nursing facility residents must maintain in the agency

files the name of each nursing facility with whom the hospice has an

agreement and the effective date of the agreement.

601.3.9. The Hospice agency is responsible for assuring the continuity and quality

of patient care whether the individuals receiving services by hospice staff

or by a contracted individual or entities.

601.3.10. Each hospice agency location must be separately licensed and submit

separate applications for enrollment even if owned or operated by the

same person(s), business or corporation, and may be conducting business

under the same trade name.

601.3.11. The hospice agency must notify Provider Enrollment at the fiscal agent

and the Division in writing of changes in enrollment status such as name

change, new address and telephone number, dissolution of corporation,

voluntary termination from the program, loss of certification or licensure,

filing of bankruptcy petitions or changes in ownership. Each notice of

change must include the date on which the change is to be effective.

601.3.12. The hospice agency must disclose ownership information pursuant to

Section 106 of the Part I Policies and Procedures manual to the Division

upon initial enrollment and annually thereafter. The hospice agency may

provide a copy of the Office of Regulatory Services Ownership

Disclosure Form or a copy of the completed Division’s Ownership

Disclosure form. These documents must be submitted to the Provider

Enrollment Unit.

601.3.13. The hospice agency must agree to periodic, on-site patient care reviews

and financial audits by authorized representatives of the Division.

601.3.14. The hospice agency must have established policies on informing patients

of the Patient Bill of Rights, provide information on the Patient’s Bill of

Rights and clinical records must contain documentation that such

information was provided.

601.3.15. The claim life cycle is the timeline for the total claim process from the

date of service to original submission and through the last date by which

resubmission (provider adjustment) must occur to remain timely.

601.3.16. All claim submissions and adjustments for denied claims are to be

completed according to DCH policy by no later than 365 days. After

which, no adjustments or override requests will be honored. Failure to

file a claim so that it is received within six (6) months after the month in

which service was rendered and/or failure to obtain prior approval or

precertification when required will result in the denial of the claim.

601.3.17. If a member has a type of Medicaid in GAMMIS (SSI, Title XIX, QMB,

SLMB, S99, etc.), during the time in which a member is in a Nursing

Facility and/or Hospice, the provider should bill and receive those

denials, which will lock in their rendering service/span dates and prevent

claims from denying untimely.

601.3.18. If a member has active eligibility with SSI or Title XIX, claims are to be

submitted within 6 months and kept timely until the Nursing Home

segment/Level of Care/Aid Category or Hospice lock-in has been

approved/updated. Retro eligibility will not be automatically granted if

the member has active eligibility with Medicaid during the dates of

service.

601.3.19. All Hospice Date of Death (DOD) lock-in requests will be considered

and approved through Gainwell Technologies if all necessary

documentation is submitted complete, legibly signed, and within 30 days

of the member electing to receive Hospice services. A DOD lock in will

not be granted if the provider fails to meet timely requirements, therefore

a timely override request would not be appropriate.

601.3.20. Once Long-Term Care eligibility is established, the claims will process

in the cycle as the system is designed to do. Providers are not to wait for

the Department of Family & Children Services (DFCS) to change the

category of service to bill when the member has Medicaid eligibility in

the system. For more detailed information, providers should review the

timely submission of claims policy outlined in Chapter, 200, Section 202

of the Medicaid/PeachCare for Kids (Part I) Policies and Procedures

Manual.

601.3.21. Claims will be denied under Section 202.1(c) regardless of:

601.3.21.1. A provider’s unawareness of a patient’s

Medicaid/PeachCare for Kids eligibility unless the

determination of the patient’s eligibility was pending on

the date of service. It is the responsibility of a provider

to verify the eligibility of a Medicaid or PeachCare for

Kids member on each date of service. If a provider fails

to submit a claim or request prior approval in a timely

fashion because of unawareness of a patient’s

Medicaid/PeachCare for Kids eligibility, even if that

unawareness was caused by action or inaction on the part

of the patient, the settlement of associated claims for

services is between that provider and that patient as the

Division will not bear financial responsibility.