La. Medicaid Services Manual ch. 24 (Hospice), Appendix A

Purpose of Form

The Bureau of Health Services Financing ( BHSF) Form Hospice – Notice of Election (NOE) is

used to notify the Hospice Prior Authorization Unit (PAU) of a hospice beneficiary’s voluntary

election or cancellation of the Hospice Program.

This form is also used to update changes in the beneficiary’s condition and status.

Upon completion, the form along with the Certification of Terminal Illness (CTI ), physician

narrative, and all related documentation must be sent to:

Gainwell Technologies via the e-PA system

@Lamedicaid.com

NOTE: Electronic submissions are required due to the time-frames.

Notifications and Type of Bill

The alpha character for the third digit of the BHSF Form Hospice – NOE’s field titled “Type of

Bill” is used to indicate the type of notification that is being provided.

Notification Type Bill Description

NOE 81A/82A When a beneficiary elects Medicaid hospice care, the

beneficiary must sign and date the BHSF Form Hospice -

NOE. The hospice provider is required to submit this form

as a NOE i mmediately after obtaining the receipt and

receipt of the physician's completed BHSF Form Hospice

– CTI, including verbal certification where applicable.

Both the forms, properly completed must be received by

the Hospice Program within 10 calendar days following the

initiation of hospice care. If this requirement is not met,

reimbursement is not available for the days prior to receipt

of the forms. Reimbursement will become effective the

date the hospice PAU receives the proper documentation.

Notice of Termination 81B/82B This notice is used for a beneficiary who has

revoked/discharged from a hospice election period. This

must be sent to the Hospice P AU within five calendar of

discharge or revocation. For revocation, a signed written

statement by the beneficiary or legal representative must

accompany the form with 81/B noted. In addition, the

beneficiary’s or legal representative’s contact information

must be provided.

Notice of Change

(Transfer)

81C/82C A Notice of transfer is sent when the beneficiary is in the

middle of an election period and wants to change hospice

providers. A beneficiary may change hospices once each

election period. The date of discharge from the current

hospice must ideally be only one day before the date of

admission to the newly designated hospice. These

providers must communicate with each other to decide

how the coordination of the beneficiary’s hospice care will

be handled. The first hospice should send the beneficiary’s

history and plan of care (POC) to the new hospice. The first

hospice must submit the notice of transfer to the hospice

PAU within five calendar days after receipt of the filed

notice of change statement. The new hospice provider must

submit the Notification of Transfer (81C/82C) to the

Notification Type Bill Description

Hospice PAU within five calendar days of transfer. The

date of admission on the Notification of Transfer should be

the date the beneficiary was admitted into the new hospice.

NOTE: An 81C/82C must also be sent to the Hospice

PAU when a beneficiary is transferring to or from a

nursing facility.

Notice of Void (of a

NOE)

81D/82D This notice is used to void an 81A/82A that was established

in error, such as if the beneficiary changes their mind, or if

the wrong Date of Admission was previously submitted.

Please note: A notice of void will not be honored if

submitted to avoid payments to non-hospice providers.

Notice of Void s must be submitted within five calendar

days.

NOTE: If claims have processed during the voided

election period, claims must be voided before 81D/82D is

submitted and a recoupment made to the intermediary.

Instructions for Completing the BHSF Form Hospice-Notice of Election

Completing the BHSF Form Hospice

PART I

The first section of the form (PART I) is to be completed by the beneficiary or legal

representative only. The signature of the beneficiary or leg al representative is required. The

beneficiary or legal representative may sign prior to the admission date or on the admission date,

but not after the admission date. The legal representative must show relationship to the

beneficiary and provide contact information.

1. Election/Admission Date - REQUIRED

The date of admission cannot precede the physician's certification by more than two calendar days,

and is the same as the certification date if the certification is not completed on time. The date must

be e ntered by the beneficiary or legal representative. Hospice providers are prohibited from

entering information in this field.

NOTE: If the BHSF Form Hospice - NOE form and the CTI are not received within 10 calendar

days of the initiation of hospice care, the date of admission (election) will be the date the Hospice

PAU receives the proper documentation. This rule applies to beneficiaries receiving Medicaid

only, as well as Medicaid/Medicare (dual eligible) beneficiaries.

EXAMPLE: The hospice election dat e (admission) is January 1, 2019. The physician's

certification is dated January 3, 2019. The hospice date for coverage and billing is

January 1, 2019. The first hospice benefit period e nds 90 days from January 1,

2019. However, if the required forms and completed packet is not received within

the 10 calendar day timeframe, the benefit begin date will be the date the

completed packet is received by the hospice PAU. For example, if the required

forms and completed packet are received on January 11, 2019, the begin date

would be January 11, 2019.

The admission date will change when the beneficiary re-elects hospice any time after a revocation

or discharge.

2. Signature of Patient/Legal Representative – REQUIRED

The signature of the beneficiary or le gal representative is required. The beneficiary or legal

representative may sign prior to the admission date or on the admission date, but not after the

admission date. The date of signature will become the LD H approval date if signed after the

admission date.

In cases where a beneficiary signs the NOE form with an “X”, there must be two witnesses to sign

next to the beneficiary’s mark. The witnesses must also indicate relationship to the beneficiary and

daytime phone number. One witness must be a relative or legal representative. Hospice

representatives cannot sign as a witness.

Definition of Relative

A relative is defined as all persons related to the beneficiary by virtue of blood, marriage, adoption

or legal guardians as court appointed.

Non-Relatives

Persons other than relatives signing the BHSF Form Hospice - NOE must have legal rights, ( a

medical power of attorney ) to make medical decisions for beneficiaries who are physically or

mentally incapacitated. Proof of these rights must be notarized or court issued documents and

submitted at the time the election for hospice is made. Verbal elections are prohibited.

3. Date of Signed - REQUIRED

The beneficiary or legal representative must enter date at time of signature.

4. Representative’s Daytime Phone Number - REQUIRED

The legal representative must provide their contact information including the area code.

5. Printed Name of Above Signee – REQUIRED

The person who signed acknowledgement of Patient’s De claration must also print name. This

could be the beneficiary or the authorized representative, whichever has signed.

6. Legal Representative’s Relationship to Patient - REQUIRED

The legal representative must show relationship to the beneficiary. If the legal representative is not

related to the beneficiary, follow the instructions as outlined in number two above.

PART II

The second section of the form (PART II) is to be completed by the hospice provider.

NOTE: When revoking hospice services, the beneficiary or legal representative must complete the

reason for revocation.

Patient Information

7. Patient Name - REQUIRED

Enter the beneficiary’s first name, middle initial and last name in this order as it is printed on the

beneficiary’s Medicaid card.

8. Patient Address - REQUIRED

Enter the beneficiary’s complete mailing address, including zip code.

9. Patient Medicaid ID Number - REQUIRED

Enter the beneficiary’s 13-digit Medicaid identification (ID) number exactly as it appears in the

beneficiary’s current Medicaid information using the plastic Medicaid “swipe” card, electronic

Medicaid Eligibility Verification System (e-MEVS), or Recipient Eligibility Verification System

(REVS). Make certain that the last two digits are the correct individual suffix for your beneficiary.

The number must match the beneficiary’s name. If the patien t is not eligible for Medicaid,

reimbursement is not made by Medicaid.

NOTE: Providers enrolling patients with “Pending” ID numbers are assuming responsibility for

those patients. It is the provider’s responsibility to notify the hospice PAU when beneficiaries

have been approved for Medicaid.

10. Patient Medicare ID Number – REQUIRED, IF APPLICABLE

This field should only be used if the beneficiary has Medicare. Enter the beneficiary’s Medicare

health insurance number.

11. Patient Date of Birth (DOB) - REQUIRED

Enter the month, day and year of birth (MM-DD-YYYY) of beneficiary. Example: 06-12-1903.

12. Type Bill - REQUIRED

Enter the three-digit numeric type of bill code, as appropriate. The first digit identifies the

type of facility. The second classifies the type of care. The third is referred to as a “frequency”

code and it indicates the sequence of this bill in this particular episode of care.

Code Structure:

1st Digit - Type of Facility

8 - Special facility (hospice)

2nd Digit - Classification

1 - Hospice (Non-hospital based)

2 - Hospice (Hospital based)

3rd Digit - Frequency Definition

A - Hospice Admission Notice Use when the hospice is submitting form as an

admission notice.

B - Hospice Termination/ Revocation Notice Use when the hospice is submitting form as a notice

of termination/revocation for a previously posted

hospice election.

C - Hospice Change of Provider Notice Use when form is used as a notice of change in the

hospice provider or nursing facility.

D - Hospice Election Void/Cancel Use when form is used as a notice of a void/cancel

of hospice election.

E - Hospice Change of Ownership Use when form is used as a notice of change in

ownership for the hospice.

13. Statement Covers Period – REQUIRED, IF APPLICABLE

This field is to be used when filing an 81B/82B document and upon the initial election of hospice

only. The “From” date is the start date of the period from which the beneficiary is revoking. The

“Through” date is the date of revocation. Dates must be entered numerically as MM-DD-YYYY.

“From” date must match the date the beneficiary/legal representative elects the hospice service.

14. Primary Diagnosis Code(s) - REQUIRED

Use the most specific and accurate numeric International Classification of Diseases (ICD)-10-CM

diagnosis code(s) for the terminal illness that is current. The principal diagnosis is defined as the

condition established after study to be chiefly responsible for the beneficiary’s admission. The

Centers for Medicare and Medicaid Services ( CMS) only accepts ICD -10-CM diagnostic and

procedural codes using definitions contained in the Department of Health and Human Services

(DHHS) Publication No. (PHS) 89- l260 or CMS approved errata and supplements to this

publication. CMS approves only changes issued by the Federal ICD -10-CM Coordination and

Maintenance Committee. Use full ICD-10-CM or its successors’ diagnoses codes including all five

digits where applicable.

15. List All Other Diagnosis Codes - REQUIRED

Enter the full ICD-10 or its successors’ codes, including all five digits where applicable, for any

other terminal diagnosis and or related condition. List ALL co-morbidities.

16. Discharge/Revocation Reason(s) - REQUIRED

Enter the reason(s) for the discharge or revocation. Beneficiary or legal representative must sign

and date NOE form if the beneficiary is revoking hospice services.

The beneficiary or legal representative must also provide a statement for the reason of revoking

services.

The hospice provider must sign and date if the beneficiary is discharging. The hospice provider

must also provide the reason the beneficiary is being discharged.

Forms received after the specified time limits will become effective upon date of receipt.

Provider Information

17. Hospice Provider Name - REQUIRED

Enter the hospice provider name.

18. Hospice Address - REQUIRED

Enter the hospice provider address (street number and name, city, state, and zip code).

19. Hospice Provider Number - REQUIRED

Enter the seven-digit Medicaid provider identification number.

20. Hospice Provider Telephone Number – REQUIRED

Enter the hospice provider telephone number including area code. Fax number is optional.

21. Name of Nursing Facility or Intermediate Care Facility for Individuals with

Intellectual Disabilities (ICF/IID) – REQUIRED, IF APPLICABLE

Enter the name of the facility in which the beneficiary resides or intends to reside. Medicaid

field office staff determines long-term care (LTC) eligibility.

22. Attending Physician Printed Name - REQUIRED

Print the name of the attending physician currently responsible for referring, certifying, and

signing the individual's POC for medical care and treatment.

NOTE: The attending physician’s name must be the same on the NOE and CTI.

23. Attending Physician Provider Number - REQUIRED

Enter the attending physician’s seven digit Medicaid provider ID number.

24. Hospice Relationship Status - REQUIRED

Enter the word "employee" or "non-employee" here to describe the relationship the beneficiary’s

attending physician has with the hospice. "Employee" also refers to a volunteer under your

jurisdiction.

25. Hospice Provider’s Representative’s Signature – REQUIRED

Signature required.

26. Hospice Provider’s Representative’s Printed Name – REQUIRED

Printed name required.

27. Date – REQUIRED

Hospice representative must enter date at time of signature.