S.C. Medicaid Hospice Services Provider Manual § 5

PRIOR A UTHORIZATION

SCDHHS requires prior authorization for Medicaid hospice services and medical record review

prepayment from the Quality Improvement Organization(QIO). All requests for prior authorization

must be received by the QIO before the service is performed. In an emergency or any unplanned

situation, the request must be received by the QIO within five business days of the date of service.

The response time for a decision by the QIO is five business days from the receipt of the request. If

a review requires a physician consultation, the QIO will have one additional business day to render

the decision.

All requests for additional information from the QIO must be received by the QIO within two

business days of the date requested.

Beneficiaries that have other primary insurance will only require prior authorization by the QIO if the

primary insurer denies the service and Medicaid is expected to pay as primary.

If a Beneficiary receives Medicaid eligibility after the service has been performed, providers must

indicate this at the time of the request. The QIO will not validate these retro requests, however

SCDHHS will audit these cases on a monthly basis.

All hospice services except GIP care may be pre-authorized for up to six months. If the beneficiary

is in need of hospice services beyond the initial six months, the hospice provider must submit a new

request to the QIO for an additional six months. Subsequent packets must include the above

documentation and be received within 15 days from the termination date of the previous approval

date or no later than two days after the termination date.

Upon admission into GIP, prior authorization request must be submitted to the QIO along with

documentation to support the need for such services within five business days. Documentation

required for a direct admission into GIP upon the election of the Medicaid hospice benefit includes

the Medicaid Hospice Election Form (SCDHHS Form 149), physician’s verbal order, the initial care

plan or the patient’s admission assessment, and supporting documentation. Written certification

must be obtained prior to the submission of hospice claims if additional hospice procedure codes

are requested for prior authorization. For admissions into GIP after business hours or during

holidays, the hospice must submit a request the next business day. GIP care may be pre-authorized

for up to 30 days. If the beneficiary is in need of additional care beyond the 30 days, clinical

documentation must be received to support the need for continued GIP care.

Hospice room and board services (procedure code T2046) do not require prior approval.

Request for prior authorization for hospice services can be submitted to the QIO at

http://scdhhs.kepro.com or by using one of the following methods:

QIO Customer Service Phone: (855) 326-5219

QIO Fax Number: 855-300-0082

Provider Issues email: atrezzoissues@kepro.com

For dually eligible beneficiaries, submit all program-related forms directly to SCDHHS:

SC Department of Health and Human Services

Hospice Program Area

Post Office Box 8206

Columbia, SC 29202-8206

Or

hospiceforms@scdhhs.gov

For Medicaid-only or Medicare Part B-only beneficiaries, in which Medicaid is the primary payer of

services or Medicaid payment will be requested as a secondary payer, hospice services must be

approved by the QIO. For dually eligible beneficiaries for Medicare is the primary payer of hospice

services, prior authorization is not required upon the election of the Medicaid hospice benefit.

However, the forms for election, revocation and/or discharge of the hospice benefit must be

submitted to SCDHHS.

To complete the prior authorization process, the following documentation must be submitted for

review:

• QIO Prior Authorization Hospice Request Form.

• Medicaid Hospice Election Form (DHHS Form 149).

• Medicaid Hospice Physician Certification/Recertification Form (SCDHHS Form 151).

• Hospice POC.

• Clinical information and other documentation that supports the medical prognosis and shows the

degree of impairment.

Clinical documentation may include, but not be limited to, current subjective and objective medical

findings, related diagnosis(es), current medications and treatment orders and a summary of current

medical treatment.

POC

Providers must design a POC for each beneficiary before rendering hospice services. This plan

must be established on the same day as the assessment if the day of assessment is to be a

covered day of hospice care.

In establishing the initial POC, the member of the basic interdisciplinary group who assesses the

patient’s needs must meet with or call at least one other group member (nurse, physician, medical

social worker or counselor) before writing the initial POC. At least one of the persons involved in

developing the initial plan must be a nurse or physician. The other two members of the basic

inter-disciplinary group must review the initial POC and provide their input to the process of

establishing the POC within two calendar days following the day of assessment. A physician must

sign the established POC.

Physician Certification

The hospice must obtain certification that an individual is terminally ill in accordance with the

procedures below, using the Medicaid Hospice Physician Certification/Recertification Form

(SCDHHS Form 151).

No certification or recertification forms are required if the beneficiary has also elected the Medicare

hospice benefit. In other words, the certification or recertification notification for dual eligibility, when

Medicare is primary, is not required.

The hospice must ensure that all the following conditions are met:

• The attending physician must be a Doctor of Medicine or osteopathy and be identified by the

individual at the time of hospice election as having the most significant role in the determination

and delivery of the individual’s medical care.

• For the first election of hospice coverage, the hospice must obtain, no later than two calendar

days after hospice care is initiated, (that is by the end of the third day), written certification

statements signed by the medical director of the hospice or the physician member of the

hospice interdisciplinary group and the individual’s attending physician (if the individual has an

attending physician).

• If the hospice does not obtain a written certification within two days after the initiation of hospice

care, a verbal certification may be obtained within these two days, and a written certification

must be obtained before a request for prior authorization of payment for hospice services. If

these requirements are not met, no payment can be made for days prior to the certification.

Certifications may be completed no more than fifteen days prior to the effective date of the

election.

• For any subsequent period, the hospice must obtain, no later than two calendar days after the

beginning of that period, a written certification statement using SCDHHS Form 151, prepared by

the medical director of the hospice or the physician member of the hospice’s interdisciplinary

group. The certification must include the physician’s signature and a statement that the

individual’s medical prognosis is of a life expectancy of six months or less if the terminal illness

runs its normal course.

The hospice must retain the certification statements in accordance with South Carolina statute of

limitations requirements. For beneficiaries that are eligible for Medicaid only, a copy of the initial

physician certification statement and when applicable, recertification statements must be submitted

with the prior authorization request.