Ga. Medicaid Part II Policies & Procedures for Hospice Services § 709

(See Appendix C for Forms)

To be timely, Hospice Election (DMA 579), Certification, Revocation, Transfer and Discharge forms

must be submitted to the Division within thirty (30) calendar days of the date that the patient signs

and/ or elects, certified, recertified, revokes, transfers or is discharged from hospice care.

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. If you need to submit updated documentation,

please fax it to Member Enrollment at 1-866-483-1044. All faxes must be accompanied with a

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

To dispute a lock-in date you must contact Gainwell Technologies Enterprise Services in

writing via fax at the fax number indicated above.

Verification of the date that your agency faxed or mailed the document to the Division will be

required when a request is made to alter any hospice effective dates. A copy of your agency’s fax

confirmation sheet that includes the date the fax was sent; the phone number and the name of the

patient should be maintained to use as verification if the hospice agency should need to dispute the

lock-in date of any individual. The copy is subject to Division review for approval or denial.

Mailing the forms does not provide a viable means to verify the timeliness of your submission.

Therefore, the hospice agency must track their forms to make sure they are submitted and received

by the Division timely. Contact Provider Inquiry at 800-766-4456 or use the Web Portal to verify

information regarding your hospice forms and effective dates.

NOTE:

DO NOT fax hospice forms to DCH unless requested to do so. Forms faxed to DCH without prior

authorization will be sent to the fiscal agent and could further delay the entry of the forms into the

system.

Election forms received by the fiscal agent past the 30-day timeframe are approved on the date of

receipt. When the election form is received after the established timeframe and the client’s date of

death is noted to be before the date of receipt, the fiscal agent will not process the election form. The

election form will be returned to the provider with the above reason indicated on the cover letter.

(The fiscal agent or Division will take no further action on election forms in this category.)

The Division will not reimburse for any forms submitted to the fiscal agent that have been altered in

a manner inconsistent with acceptable standards of medical practice. The fiscal agent will return any

altered forms of this nature to the provider. The effective date of the form will be amended to the

date of receipt of the resubmitted form.