Ga. Medicaid Part II Policies & Procedures for Hospice Services § 707

An individual may change the designation of the hospice agency from which he or she elects to

receive hospice care once in each benefit period. The change of the designated hospice agency is not

considered a revocation of hospice benefit. To change the designation of hospice agency providers,

the individual must file with the current hospice agency and with the newly designated hospice

agency, a Rev. 01/14 signed Hospice Transfer Form. The transferring hospice agency must

specify in writing the last day of service to be included for billing (end date) and forward a copy

to the newly designated hospice agency within five (5) calendar days.

The receiving hospice agency must complete a Medicaid Hospice Election Form for the individual

transferring to their agency compliant with Section 702. The hospice agency must notify DFCS of

the Medicaid individual transfer by completing the top portion and Remarks Section of the Hospice

Care Communicator. The receiving hospice must specify on the transfer from the start date of

hospice service with their agency.

Medicaid will not pay two hospices for services on the same date. A copy of the current Hospice

Election Form and physician certifications must accompany the transfer form to the receiving

hospice agency. The transferring and receiving hospice agencies are required to maintain the transfer

form, election form and the physician certification form for the current benefit period in the

individual’s medical record. The receiving hospice agency must submit the Medicaid Transfer Form

and the Medicaid Hospice Election Form completed for their agency to the Division. The Change of

Hospice/Transfer form must include the following information at a minimum:

707.1. Individual’s name, address, telephone number, date of birth, Social Security Number,

and Medicaid number.

707.2. Transferring Hospice name, address, telephone number and Medicaid Provider Number.

707.3. Effective date of transfer (End Date of Service). This is the last date that the transferring

hospice agency can bill.

707.4. Receiving Hospice name, address, telephone number and Medicaid Provider Number.

707.5. Effective Date of service (Start Date). This is the date that the receiving agency will

begin providing services. The start date cannot be the same as the end date.

707.6. Comments Section.

707.7. Hospice Diagnosis.

707.8. Date the form is completed by the transferring hospice.

707.9. Signature of the authorized representative of the transferring hospice.

707.10. Signature of the authorized representative of the receiving hospice and date.

707.11. Signature of individual or individual’s representative.

707.12. Effective date of receipt (This is the first date the receiving hospice may bill).

A change of ownership of a hospice agency is not considered a change in the member’s

designation of hospice and requires no action on the member’s part. Refer to Section 602

regarding change of ownership of hospice agencies. The Division of Medical Assistance requires

that the Medicaid specific hospice transfer form found in Appendix C be used for individuals who

are Medicaid eligible and are transferred to another hospice services.