Ga. Medicaid Part II Policies & Procedures for Hospice Services § 802

Services provided by certain Medicaid providers for care not related to the terminal illness may be

reimbursed by the Division directly to the non-hospice providers. Non-hospice related conditions are

not related to the terminal illness and are not included in the hospice plan of care. Services that may

be non-hospice related include but are not limited to:

802.1. Hospital.

802.2. Pharmacy.

802.3. Durable Medical Equipment.

802.4. Emergency and non-emergency transportation.

802.5. Laboratory; and

802.6. Specialty physician services.

The hospice agency must provide the non-hospice service provider with a Hospice Referral

Form for Non-Hospice Related Services (See Appendix C).

A copy of the referral form must be maintained in the individual’s hospice medical record. The

Division will not reimburse the non-hospice provider for nonhospice related services without the

Hospice Referral Form. Non-Hospice Services provided through Medicaid programs must follow the

policies and procedures manual applicable to the service. If a prior approval is required for the

service that is not hospice related, a prior approval must be obtained by the nonhospice provider.

The hospice agency is responsible for all services related to the terminal illness and any condition

related to the terminal illness, including inpatient care and outpatient services. If care/services are

required by a hospice patient that is Unrelated to the hospice diagnosis, the provider of that

care/service must first contact the hospice agency to obtain the hospice diagnosis of the patient

before rendering care/service.

The provider of the non-hospice related care/service also has the option of

obtaining the form. The form can be accessed by downloading the Non-Hospice Related Referral

Form. Go to www.mmis.georgia.gov, select the Provider Information tab, click on Forms, scroll

down to and click on the DMA -521 form.

The Non-Hospice Service Provider must obtain the hospice diagnosis to be inserted on the Non-Hospice Related Referral Form PRIOR TO RENDERING CARE/SERVICE. Failure to do so may

result in the denial of the provider’s claim.