N.C. Medicaid Clinical Coverage Policy No. 3D § 5.6.1

The provider of hospice services shall comply with 42 CFR §418.24 (a) Filing an

election statement, and upload the election statement into NCTracks as part of the

initial PA request for hospice services.

a. Submission of the election statement must be within six calendar days of the

effective date, in order to be paid from the beneficiary’s date of election into

Hospice services. If not submitted within six days of election, Medicaid

coverage shall not begin until after the election statement is uploaded into

NCTracks. These days are a provider liability, and the provider shall not bill

the beneficiary for these non-Medicaid covered days. If beneficiary is

physically or mentally incapacitated, his or her representative (as defined in

§418.3) may file the election statement.

b. Exception to the consequences for filing the Election Statement late may

be waived NC Medicaid determines if a circumstance encountered by a

hospice is exceptional and qualifies for waiver. A hospice shall fully

document and furnish any requested documentation to NC Medicaid for a

determination of exception.

Note: If Medicare is the primary payer, and Medicaid is providing coverage for

nursing home room and board the provider shall create a prior approval request in

NCTracks and upload the Election Statement into the initial PA for room and

board.