La. Medicaid Services Manual ch. 24 (Hospice) § 24.6

Prior authorization (PA) is required upon the initial request for hospice coverage. Requests for PA

must be submitted within seven calendar days of the hospice election date. If the PA is approved,

it covers 90 days. If another 90-day election period is required, the PA request must be submitted

at least seven calendar days prior to the end of the current election period. This will ensure that

requests are received and approved/denied before the preceding period ends. If this requirement is

not met and the period ends, reimbursement will not be available for the days prior to receipt of

the new request. If approved, reimbursement will be effective the date the Prior Authorization Unit

(PAU) receives the proper documentation.

The completed PA (see Required Documentation in this section,) which includes the updated and

signed “Hospice Certification of Terminal Illness (CTI)” (Bureau of Health Services Financing

(BHSF) Form Hospice - CTI) and all related documents, must be received before the period ends.

Any PA request received after the period has ended will become effective on the date the request

is received by the PAU if the request is approved. This policy also applies to PA packets received

after Medicaid eligibility has ended. It is the responsibility of the provider to verify eligibility on

a monthly basis. The PA only approves the existence of medical necessity, not beneficiary

eligibility. (See Appendix B for detailed information regarding BHSF Form Hospice - CTI).

All requests for hospice PA must be submitted to Gainwell Technologies through their electronic

prior authorization (e-PA) system. No other form or substitute will be accepted.

Electronic Prior Authorization

The e-PA system is a web application that provides a secure web-based tool for providers to submit

PA requests and to view the status of previously submitted requests. For more information

regarding e-PA, visit the Louisiana Medicaid web site or call the PAU.

NOTE: PA is not required for dual eligible beneficiaries (Medicare primary) during the two

90-day election periods and the subsequent 60-day election periods. However, they must submit a

copy of the Medicare Common Working File screen showing the hospice segment through the e -

PA system and the signed CTI and Notice of Election (NOE) forms.

Required Documentation

Documentation should paint a picture of the beneficiary’s condition by illustrating the

beneficiary’s decline in detail (e.g. documentation should show last month’s status compared to

this month’s status and should not merely summarize the beneficiary’s condition for a month). In

addition, documentation should show daily and weekly notes and illustrate why the beneficiary is

considered to be terminal and not “chronic”. Explanation should include the reason the

beneficiary’s diagnosis has created a terminal prognosis and show how the systems of the body

are in a terminal condition. Telephone courtesy calls are not considered face-to-face encounters

and will not be reviewed for PA.

The following information will be required upon the initial request for hospice services.

First Benefit Period (90 days)

1. Hospice Election Form ( primary diagnosis code(s) using the International

Classification of Disease (ICD), Tenth Revision (ICD -10) or its successor; other

codes);

2. Hospice - CTI Illness form (BHSF Form Hospice – CTI);

3. Clinical/medical information;

4. Hospice provider plan of care (POC) includes the following:

a. Progress notes (hospital, home health, physician’s office, etc.);

b. Physician orders for POC; and

c. Include Minimum Data Set (MDS) or jRaven form (original and current) if

beneficiary is in a facility; weight chart; laboratory tests; physician and

nursing progress notes. The MDS/jRaven form (original and current) is

not required if the beneficiary has been in a long-term care facility less

than 30 days. The MDS /jRaven form must be provided upon the

subsequent request for continuation of hospice services.

5. Documentation to support beneficiary’s hospice appropriateness must include the

following:

a. Paint picture of beneficiary’s condition;

b. Illustrate why beneficiary is considered terminal and not chronic;

c. Explain why their diagnosis has created a terminal prognosis; and

d. Show how the body systems are in a terminal condition.

Second and Subsequent Periods

Providers requesting PA for the second period, and each subsequent period, must send the request

packet to the PAU at (see Appendix D for Contact/Referral Information) that includes the

following:

1. MDS/jRaven forms (original and current) are required; weight chart; laboratory

tests; physician and nursing progress notes if the beneficiary resides in a nursing

facility;

2. An updated Hospice - CTI form (BHSF Form Hospice - CTI) and a face-to-face

encounter signed and dated by the hospice provider’s medical director or physician

member of the interdisciplinary team (IDT) for the third and subsequent requested

PA periods;

3. An updated POC;

4. Updated physician’s orders;

5. List of current medications (within last 60 days);

6. Current laboratory/test results (within last 60 days if available);

7. Description of hospice diagnosis;

8. Description of changes in diagnoses;

9. Progress notes for all services rendered (daily/weekly physician, nursing, social

worker, aide, volunteer and chaplain);

10. A social evaluation;

11. An updated scale such as: Karnofsky Performance Status Scale, Palliative

Performance Scale or the Functional Assessment Tool (FAST);

12. The beneficiary’s current weight, vital sign ranges, lab tests and any other

documentation supporting the continuation of hospice services. Documentation

must illustrate the beneficiary’s decline in detail. Compare last month’s status to

this month’s status; and

13. Original MDS/jRaven; current MDS/jRaven form if beneficiary is a resident in a

facility.

This information must be submitted for all subsequent benefit periods and must show a decline in

the beneficiary’s condition for the authorization to be approved.

For PA, the prognosis of terminal illness will be reviewed. A beneficiary must have a terminal

prognosis in addition to a completed Hospice - CTI form and proof of the face-to-face

encounter. Authorization will be made on the basis that a beneficiary is terminally ill as defined

in federal regulations. These regulations require certification of the prognosis, rather than

diagnosis. Authorization will be based on objective clinical evidence in the clinical record about

the beneficiary’s condition and not simply on the beneficiary’s diagnosis.

A cover letter attached to the required information will not suffice for supporting documentation.

The supporting information must be documented within the clinical record with appropriate dates

and signatures.

Example: A beneficiary receives hospice care during an initial 90-day period and is discharged or

revokes their election of hospice care during a subsequent 90-day period, thus losing any remaining

days in that election period. If this beneficiary chooses to elect a subsequent period of hospice

care, even after an extended period without hospice care, prior authorization will be required. The

NOE, Hospice CTI form, and all PA documentation are due within the 10 day time frame.

Reimbursement will be effective the date the required information is received by the PAU if receipt

is past 10 days.

A provider, who anticipates the possibility of providing hospice care for a beneficiary beyond the

initial 90-day election period, must submit a PA packet to the PAU. The required information and

any supporting documentation must be sent.

Written Notice of Prior Authorization Decision

PA requests will be reviewed using the Medicare criteria found in local coverage determination

hospice determining terminal status (L34538) and approved or denied within five working days.

Once the review process has been completed and a decision has been made, the hospice provider

will receive a written notification of the decision. A denial does not represent a determination that

further hospice care would not be appropriate, but that based on the documentation provided, the

beneficiary does not appear to be in the terminal stage of illness. Providers are encouraged to

submit PA packets for the next subsequent period within the set time frame when there is evidence

of a decline in health if a prior period had been denied.

NOTE: It is the hospice provider’s responsibility to inform the nursing facility of approval or

denial.

Reconsideration

If a beneficiary does not agree with the denial of a period or subsequent period, reconsideration

may be requested. Documentation must be recent and not for dates that were previously omitted

or previously submitted. All reconsideration requests will be reviewed within five working days

from the receipt of the written request.