N.C. Medicaid Clinical Coverage Policy No. 3D § 5.12.4

The hospice provider shall report initial hospice participation to NC Medicaid

when a beneficiary elects Medicaid hospice benefits.

The hospice provider shall submit a PA request:

a. initially, within six calendar days of the election of the Medicaid, Medicaid

pending hospice benefit;

b. within six calendar days of the start of the second and each subsequent benefit

period; and

c. within six calendar days of the start of care, if Medicare is the primary payer,

and Medicaid is providing coverage for nursing home room and board.

The hospice provider shall report to NC Medicaid by faxing the NC Medicaid

Hospice Reporting Form (DMA-0004) for the following situations:

a. if the beneficiary is discharged from or revokes hospice;

b. at the time of the beneficiary’s death;

c. to coordinate reporting a transfer of hospice care from one provider to another

to prevent duplication of dates of service and subsequent denial of payment as

only one provider can be paid each day; and to notify NC Medicaid of

changes in status from Medicaid-Pending to Medicaid-Approved by providing

the MID number.

Note: Hospice providers that fail to provide all required documents for prior

approval to NC Tracks, may be referred to the Office of Compliance and Program

Integrity (OCPI).