N.H. Medicaid Hospice Provider Manual, Vol. II, § 6

Hospice providers must maintain supporting documentation, including copies of forms submitted to the

Department, for each service for which a claim has been submitted to NH Medicaid for reimbursement.

Please see the “Record Keeping” section of the General Billing Manual – Volume I, for documentation

requirements.

Providers must maintain clinical records to support claims submitted for reimbursement for a period of at

least six years from the date of service or until resolution of any legal action(s) commenced in the six year

period, whichever is longer.

As described under “Covered Services” above, continuous home care requires documentation that clearly

indicates the nature of the medical crisis and the need for skilled intervention, including the level of

staffing and the services that were provided both hourly and daily.

Hospice providers’ records shall include forms created by the provider, which address the following and

includes the required elements (as noted in this billing manual and the rules at He-W 544):

1. A member’s election of hospice care;

2. The provider’s certification of terminal illness;

3. A change in designated hospice providers if applicable; and

4. A revocation of hospice care if applicable.

The hospice provider shall notify the Department by completing and submitting a Form 282A, “Medicaid

Hospice Care Notification Form” (found on the NH MMIS Health Enterprise portal at

www.nhmmis.nh.gov) to the Department when any of the following occur:

1. A member elects hospice care;

2. A member changes his or her designated hospice provider;

3. A member revokes his or her election of hospice care;

4. A member is discharge from the hospice provider due to the member’s death.

Within 30 days following the end of each quarter, for each member who died within that quarter, the hospice

provider shall notify the Department of hospice service utilization by completing and submitting a Form

282B, “Service Utilization within Hospice by Recipient,” found on the NH MMIS Health Enterprise portal at

www.nhmmis.nh.gov. This form is not required for dual-eligible hospice members who reside in a nursing

facility.

Hospice providers shall submit to the Department a copy of the provider’s annual Medicare Cost Report,

by November 30th of each year.