Ga. Medicaid Part II Policies & Procedures for Hospice Services, Appendix C

The Division will make reimbursement to hospice providers only when the hospice individual is determined to be

terminally ill as described in Section 704 of this manual. The provider may view a copy of the “Medicaid Hospice

Election Form (DMA 579)” on page C-2 of this Appendix. This form must be completed, and a copy received by

the Division within thirty (30) calendar days of the individual’s signature.

The provider may view a copy of the Medicaid Hospice Physician Certification Form (DMA 522)”, Pages C-3,4

“Medicaid Hospice Revocation Form (DMA523)”, C-5, “Medicaid Hospice Discharge Form (DMA 524)”, C-6

and “Medicaid Hospice Transfer Form (DMA 525),”, C-7 on pages of this appendix. The forms must be

completed accurately and a copy received by the Division within thirty

(30) calendar days of the appropriate signature(s).

The provider must complete and submit the “Hospice Referral Form (DMA 521)”, if the patient receives non-hospice related services. You may view instructions for completion of the form on page C-8.

The provider may view a copy of the “Hospice Care Communicator Form (DMA 527)”, C-11 and “Hospice Care

Communicator Form (Status Change) (DMA 528)”, C-12, of this appendix. These forms are included for the

convenience of the hospice agency in communicating with the local DFCS office. The forms must be completed

accurately and a copy received by the Division within thirty (30) calendar days of the appropriate signature(s). All

non-hospice providers should refer to their Billing manual for complete instructions.

All indicated hospice forms can be printed or photocopied from this manual. Please refer to Section 709 regarding

the procedure and mailing address for the submission of hospice forms.

PLEASE NOTE: THE PROVIDER MUST NOT ALTER FORMS, WHICH ARE OFFICIAL MEDICAID

HOSPICE FORMS.

MEMBER INFORMATION

MEDICAID HOSPICE ELECTION FORM

Name Address

Medicaid Number

Social Security Number Date of Birth

HOSPICE INFORMATION

Hospice Name Address

Provider Number Telephone Number

Effective Date for Hospice Care

Primary Diagnosis

ATTENDING PHYSICIAN INFORMATION

ICD Code of Primary Diagnosis

Date of Onset

_

Attending Physician Name Attending Physician Medicaid or NPI Number

Date Last Seen MM/DD/YY

ELECTION STATEMENT

• I understand that my physician has certified me as being terminally ill with a medical prognosis of six (6) months or less, if the disease runs its normal course.

• The Georgia Medicaid Hospice Services Program has been explained to me. I have been given the opportunity to discuss the services, benefits, requirements

and limitations of this program and the terms of the election statement.

• (Adults over age 21 only) I understand that by signing the election statement I am waiving all rights to regular Medicaid services except for payment to my

attending physician, treatment for medical conditions unrelated to my terminal illness, medical transportation, dental services and Medicaid pharmacy

services for prescriptions not covered under hospice.

• I understand that I will be entitled to Medicaid sponsored hospice services if I am Medicaid eligible and physician certified as required for each benefit

period. These services are provided in benefit periods for an initial ninety (90) day period, a subsequent ninety (90) day period and for each subsequent sixty

(60) day period.

• I understand that I may revoke the hospice benefit at any time by completing the appropriate form, specifying the date when the revocation is to be effective

and submitting the statement to the hospice prior to that date; however, that if I choose to revoke hospice services during a benefit period, I am not entitled to

coverage for the remaining days of that benefit period. At the same time, I revoke hospice services, I understand my rights to other Medicaid services will

resume, provided I continue to be Medicaid eligible.

• I understand that I may change the designated hospice provider, one time during a benefit period, without affecting the provision of my hospice benefits. To

change the designation of hospice providers, I must dis-enroll with the hospice from which care has been received and elect a new hospice provider.

• I understand that if I am a Medicare beneficiary, I must elect to use the Medicare Hospice Benefit.

• I understand that if I elected the Medicare Hospice Benefit and am eligible for Medicaid, I must also elect the Medicaid Hospice Benefit.

• My choice for my attending physician is:

Signatures:

Member or Representative Signature, Relationship of Representative Date

Hospice Representative Date

Nursing Facility (if applicable)

I understand that this individual’s election of the hospice benefit and waiver of Medicaid reimbursement for nursing facility services for the duration of election

under the hospice program. Medicaid reimburses the hospice provider for nursing facility room and board when the individual resides in the nursing facility and

the hospice reimburses the nursing facility for room and board charges.

Nursing Facility Representative Signature Date

DMA-579

GEORGIA MEDICAID HOSPICE PHYSICIAN CERTIFICATION FORM

MEMBER INFORMATION

Name Address

Medicaid Number

Social Security Number Date of Birth

Primary Diagnosis/ICD Code: Date of Onset:

CERTIFICATIONS MUST BE DOCUMENTED BY THE ATTENDING PHYSICIAN OR THE HOSPICE

AGENCY MEDICAL DIRECTOR OR PHYSICIAN

THE FULL NAME SIGNATURE AND THE DATE OF EACH CERTIFICATION IS REQUIRED ON THIS FORM

PHYSICIANS MUST DOCUMENT EACH CERTIFICATION AND FACE TO FACE ENCOUNTER STATEMENT

First Benefit Period (90 days): Certification #1 for FDOS- TDOS-

Signature of Member’s Attending Physician/Licensure number Signature of Hospice Medical / Licensurenumber

Date Date

Second Benefit Period (90 days): Certification #2for FDOS- TDOS

Signature of Member’s Attending Physician/Licensure number Signature of Hospice Medical / Licensurenumber

Date Date

SUBSEQUENT Benefit Period (60 days)/ Face to Face Certification Required#3: FDOS TDOS

Statement of Face-Face Encounter required:

Signature of Physician Date

DMA-522A Revised 07/15

SUBSEQUENT CERTIFICATIONS BY THE ALLOWED PHYSICIAN

[PHYSICIANS MUST SIGN FULL NAME AND DATE CERTIFICATION FORM]

SUBSEQUENT Benefit Period (60 days)/ Face to Face Certification Required,#: FDOS TDOS

Statement of Face-Face Encounter required:

Signature of allowed Hospice Physician Date

SUBSEQUENT Benefit Period (60 days)/ Face to Face Certification Required,#: FDOS TDOS

Statement of Face-Face Encounter required:

Signature of allowed Hospice Physician Date

SUBSEQUENT Benefit Period (60 days)/ Face to Face Certification Required,#: FDOS TDOS

Statement of Face-Face Encounter required:

Signature of allowed Hospice Physician Date

SUBSEQUENT Benefit Period (60 days)/ Face to Face Certification Required,#: FDOS TDOS

Statement of Face-Face Encounter required:

Signature of allowed Hospice Physician Date

SUBSEQUENT Benefit Period (60 days)/ Face to Face Certification Required,#: FDOS TDOS

Statement of Face-Face Encounter required:

Signature of allowed Hospice Physician Date

DMA-522B (Revised 07/15)

GEORGIA MEDICAID HOSPICE REVOCATION FORM

MEMBER INFORMATION

_ _

Name Medicaid Number

_ _

Date of Birth Social Security Number

_

Effective Date

PROVIDER INFORMATION

_ _

Hospice Name Telephone Number

_

Medicaid Provider Number

Revocation Statement:

• I desire to voluntarily revoke the election of hospice care.

• The Georgia Medicaid Hospice Services Program has been explained to me. I have been given the

opportunity to discuss the services, benefits, requirements and limitations of the program and the terms of

the revocation of these services.

• I understand that by signing the revocation statement that, if eligible and applicable, I will resume Medicaid

coverage of benefits waived when hospice care was elected.

• I understand I will forfeit all hospice coverage days remaining in this benefit period.

• I understand that I may at any time elect to receive hospice coverage for any other hospice benefit period for

which I am eligible.

• I, therefore, revoke the hospice benefit because

_ _

Hospice Representative Signature Member or Representative Signature

Representative’s Relationship

_ _

Date Date

MEDICAID HOSPICE DISCHARGE FORM

MEMBER INFORMATION

Name Address

Medicaid Number

Social Security Number

PROVIDER INFORMATION

Hospice Name Address

Provider Number

Telephone Number

DISCHARGE STATEMENT

Hospice benefits for the above identified individual, enrolled with this agency, has been discharged from hospice services

effective for the following reason(s): (check all that apply) Date

Prognosis is now more than six (6) months.

Individual has moved out of state/hospice service area.

Safety of individual or hospice staff is compromised. (Explanation must appear below)

Death of the individual.

Explanation:

Hospice Representative Signature Date

STATEMENT OF UNDERSTANDING

I understand I am to be discharged from hospice services effective the date above. I have been given the opportunity to discuss the services, benefits,

requirements and limitations of the program and the terms of the discharge from this service. I understand any Medicaid cover age of benefits waived

when hospice care was elected will resume. I understand that I may at any time elect to receive hospice coverage for any other hospice benefit period

for which I am eligible.

Member or Representative Signature/ Relationship Date DMA-524

MEDICAID HOSPICE TRANSFER FORM

E N D DATE:

APPLICABLE BENEFIT PERIOD: [] First 90 Days

[] Second 90 Days

[] () Period of 60 Days

MEMBER INFORMATION

Name Address

Medicaid Number

Social Security Number Date of Birth

SENDING PROVIDER INFORMATION

Hospice Name Address

Provider Number Telephone Number

Signature of Hospice Representative Date

The sending hospice must complete the above section and forward to the receiving hospice within five (5) business days of the effective date.

RECEIVING PROVIDER INFORMATION

START DATE:

The above-named individual requests that the designation of their selected hospice be changed to:

Hospice Name Address

Provider Number Telephone Number

Signature of Hospice Representative Date

The receiving provider must forward a completed copy to the Department of Community Health, Division of Medical Assistance. This form must be received by the

Department of Community Health, Division of Medical Assistance within thirty (30) days from the effective date of transfer.

Signatures:

As a member of hospice services, I understand that I may change hospice providers only once during each hospice benefit period. I also understand

that this request for a change of hospice provider is not a revocation of the remainder of my current election period.

Member or Representative Signature/Relationship Date

WITNESS SIGNATURE DATE

DMA-525

HOSPICE REFERRAL FORM FOR

NON-HOSPICE RELATED SERVICES (DMA-521) INSTRUCTIONS

This referral form MUST BE ATTACHED TO THE APPROPRIATE CLAIM FORM to verify non-hospice covered services. This form is initiated by the hospice provider and completed by the non-hospice

provider. This form should be returned to Gainwell Technologies Enterprise Services.

HOSPICE REFERRAL FORM FOR

NON-HOSPICE RELATED SERVICES

SECTION I - To Be Completed by Provider

1.

2.

Member Name Member Date of Birth

3.

Address

4.

Medicaid Number

5.

Social Security Number

6.

Hospice Name and Provider Number

7.

Address & Phone Number

8. 9.

Provider Name Provider Medicaid #

10.

Provider Address & Phone Number

11. Type of Service: [] Inpatient [] Physician [] Medicaid Waiver _

[] Outpatient [] DME [] Other (Explain)

[] Emergency

12. Non-Hospice Related Diagnosis Condition and/or Service(s):

13. Hospice Diagnosis:

SECTION II - TO BE COMPLETED BY DMA REVIEWER

Date Request for Additional Documentation

Approval/Denial Date Authorized Signature

DMA- 521 (Revised 10/15)

SECTION II COMPLETED BY DFCS MEDICAID WORKER (Check all boxes that apply)

HOSPICE CARE COMMUNICATOR

Patient Name County Medicaid # Hospice Care Coordinator

Address Soc. Sec. # Telephone # Hospice Agency Address

City State Zip Code Date of Birth Hospice Agency Name Telephone #

The above-named patient elects to receive routine hospice care services at their residential home or as a resident within a Nursing

Facility beginning. The patient’s doctor certified on that the patient’s life

expectancy is anticipated to be six months or less.

• The patient is admitted to hospice care in a nursing home as of and is currently receiving Nursing

Home Medicaid. Please change class of assistance to Institutionalized Hospice (IH).

• The family has been referred to DFCS for Medicaid eligibility and cost share determination

• The patient is deceased. Date: .

• The patient revokes hospice or discharged from hospice. Effective Destination

• The certification period extends from through.

.

Hospice Representative Signature Date Telephone # Fax Number

*FOR Gainwell Technologies PURPOSES ONLY*- ENSURE THAT A COPY OF THE ELECTION (initial) OR

CERTIFICATION (subsequent) FORM IS ATTACHED

• The date patient applied for Institutionalized Hospice (IH) Medicaid ID# .

• The patient has been determined Medicaid eligible effective.

• The patient receiving IH is responsible for contributing toward the cost of care.

• The patient monthly cost share amount: $ Effective:

• The patient has a change in cost share.

$ EFFECTIVE $ EFFECTIVE

• The patient has been denied/terminated Medicaid effective.

Reason or denial:

DFCS Worker Signature Date Telephone Number Fax Number

REMARKS:

DMA-527

SECTION III COMPLETED BY HOSPICE AGENCY or DFCS MEDICAIDWORKER

SECTION I COMPLETED BY HOSPICE CARE AGENCY (Check all boxes that apply)

HOSPICE CARE COMMUNICATOR (STATUS CHANGE)

TO: (County Office of Department of Family and Children

Services)

Or

(Hospice Care Agency)

FROM: (County Office of Department of

Family and Children Services)

Or

(Hospice Care Agency)

RE: /

Member Name Medicaid ID #

Social Security Number

(To be completed by Hospice Care Agency)

The following change has occurred in the above-named member’s situation:

[] The member expired on

(date of death)

[] The certification period for the member expired effective and the (date m/d/y)

member is not electing continued hospice care.

[] The certification period for the member expired effective and the member elects to continue hospice care

services for another certification period. The certification period extends from

(date m/d/y) through (date m/d/y)

[] The member revoked the election of hospice care for the remainder of the election period. The effective date of revocation is

(date m/d/y)

[] The member transferred to another hospice care agency on

(date m/d/y)

The name and address of the other hospice care agency is

[] The member has been discharged/decertified from the election of hospice for the remainder

of the election period. The effective date of discharge/de-certification is

(date m/d/y)

[] Other:

Signature of Director Date

DMA-528