Iowa Medicaid Hospice Provider Manual, APPENDIX B

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A. Purpose of Form

The Case Activity Report (CAR) provides a mechanism for hospice providers to

report individual member changes that may affect eligibility for a member who

receives the hospice benefit and also resides in an NF.

B. When the CAR Must be Completed

• A Medicaid-eligible or dual-eligible member enters the NF and begins hospice

on the same day.

• A member living in an NF chooses the hospice benefit.

• A dual-eligible member chooses the hospice benefit.

• The status of a dual-eligible hospice/NF member changes to Medicaid only.

• A hospice/NF member dies.

• A hospice/NF member does not qualify for or revokes the hospice benefit.

• A hospice/NF member changes or transfers to another NF or to another hospice

provider.

C. Responsibility for Completion

The hospice provider may assist the member or the legal representative with

completion of this form, if needed. The member or the legal representative must

sign and date the form.

D. Instructions

1. Member Data

Name. Enter the member’s first, middle initial, and the last name as it

appears on the Medical Assistance Eligibility Card.

Date Entered Facility. This date will be one of the following:

• If the date that hospice began is the same day that the member entered

the nursing facility, enter the day that the member entered the NF.

• If the date that hospice begins occurs sometime after the admission date,

enter the date that hospice service actually began.

Social Security Number. Enter the social security number.

State ID. This number consists of seven numeric characters and an ending

alphabetic character.

Case Number. Enter, if known. DHS income maintenance uses this

number.

2. Facility Data

Provider Number/NPI Number. Enter the NF’s provider numbers followed

by the hospice provider numbers.

Facility Type. Check “Hospice” for facility type.

Name. Enter the name of the hospice provider.

DHS Per Diem. Enter the NF’s daily reimbursement. The current rate can

be located at the following link: http://dhs.iowa.gov/ime/providers/csrp/nrf

Street Address. Enter the street address of the hospice provider.

Signature of Person Completing Form. Enter the signature of the hospice

staff completing form.

Date Completed. Enter the date the form was completed and sent to the

DHS Centralized Facility Eligibility Unit (CFEU). CFEU submission information

follows.

Contact Name. Enter the hospice contact’s name.

Contact Phone Number. Enter the hospice contact’s telephone and email

address, if available.

3. Level of Care

Hospice eligibility does not require a level of care (LOC) determination unless

the following applies:

• IME Medical Services has not completed a LOC for the NF member when

hospice begins.

• If an LOC is needed for the above reason, submit documentation for a

LOC determination in accordance with the Centers for Medicare and

Medicaid Services (CMS) Minimum Data Set (MDS) requirements.

4. Medicare Information for Either Skilled Patients or Hospice Patients

in Nursing Facilities

Do you expect this stay to be covered by Medicare? Answer “yes” or

“no” to the question. If yes, complete the next box.

Expected dates of Medicare coverage. Enter the dates of expected

Medicare coverage.

• This section will be completed for hospice/NF members who are dual

eligible and whose hospice benefit is funded by Medicare and the NF daily

reimbursement is funded by Medicaid.

• Please note: If dual eligibility ends for the hospice/NF member and full

Medicaid eligibility begins, another CAR must be completed, along with

the Election of the Medicaid Hospice Benefit, form 470-2618.

5. Discharge Data

Date of Discharge. Enter the discharge date.

The information regarding various types of days is not completed, under

“Last Month in Facility,” unless the hospice/NF member dies on the last day of

the month.

Reason for Discharge. Check the applicable box for discharge reason. If

the reason for discharge is not listed, draw in another box at the bottom and

write the reason for discharge.

6. Distribution

• Retain the original in the member’s case file.

• Submit a copy to the member or the legal representative.

• If the member resides in an NF, submit a copy to the:

• Nursing facility.

• DHS CFEU within two days of action by mail, fax or email per the

information below:

Mailing Address:

DHS CFEU

Imaging Center 1

Iowa Department of Human Services

417 E. Kanesville Blvd.

Council Bluffs, IA 51503-4470

Fax: (515) 564-4040

Email: facilities@dhs.state.ia.us