S.C. Medicaid Hospice Services Provider Manual § 6

REPORTING/DOCUMENTATION

Prior Approval of Services

Services provided by certain Medicaid providers for care not related to the terminal illness must be

pre-approved by the hospice provider. The Medicaid provider will contact the hospice provider

indicated by the South Carolina Medicaid Web-based Claims Submission Tool (Web Tool) to obtain

confirmation that the service does not relate to the terminal illness, as well as a prior authorization

number to be included on that provider’s claim form. The hospice prior authorization number on the

claim certifies that the services provided are not related to the terminal illness or are not included in

the hospice POC. If the prior authorization number is not included on the claim form, the form will be

rejected and returned to the provider. Services that require prior authorization are:

• Hospital

• Emergency Room

• Pharmacy

• Mental Health

• Drug, Alcohol and Substance Abuse Services

• Audiology

• Psychologist Services

• Speech Therapy

• Occupational Therapy

• Ambulatory Surgery Clinics

• Medical Rehabilitation Services

• School-Based Services

• Physical Therapy

• Private Duty Nursing

• Podiatry

• Health Clinics

• County Health Departments

• Home Health

• Home- and Community-Based Services (HCBS)

• DME

Non-hospice-related claims for these services will not be reimbursed without the prior authorization

number. For example, if a hospice patient is admitted to the hospital for treatment not related to

terminal illness, SCDHHS will reimburse the hospital for services directly only if the prior

authorization number appears on the claim. The hospice will continue receiving reimbursement from

SCDHHS and will be responsible for all other care and services required by the patient during the

hospitalization.

All services delivered to hospice patients, regardless of provider, will be subject to post-payment

review. A hospice that authorizes Medicaid payment for a service that is related to the terminal

illness and that should thus be provided by the hospice is subject to recoupment of the Medicaid

funds expended for the service.

A hospice provider must pre-approve all services that are not related to the terminal illness by

reviewing a request from other Medicaid providers. In each situation where the hospice provider is

authorizing that the service to be performed is not related to the terminal illness, the prior

authorization number will be the same number as the hospice provider number issued upon

contracting with the SCDHHS. It is necessary for each hospice to maintain a documentation log of

each pre-authorization action and to make this documentation available to the staff of SCDHHS

upon request. Documentation must include the service that is pre-approved, the service provision

date, the Medicaid provider, the approving hospice authority, and the date approval was issued. If a

dispute arises regarding whether a prior authorization was obtained, the documentation log will

serve as the primary basis in resolving the disagreement.

When a patient leaves a hospital and enrolls in hospice on the same day, the hospice provider must

give a prior authorization to the hospital so that the claim for the last day of hospital services can be

paid. Conversely, when a patient is discharged or revoked by a hospice program and is admitted to

the hospital on the same day, the hospice provider must give a prior authorization to the hospital so

that the claim for that day of hospital services can be paid.

The hospice provider must determine which, if any, of the prescription drugs taken by a hospice

patient are not related to the terminal illness. The hospice patient’s pharmacy must be given a prior

authorization number each time the drugs that are not related to the terminal illness are dispensed.

Hospice and HCBS Interaction (for the Community Choices (CC), Human Immunodeficiency

Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), and Mechanical Ventilator

Dependent waiver (Vent) waivers only)

Medicaid-only and dually eligible beneficiaries may receive Hospice services and HCBS with

appropriate coordination to avoid duplication. HCBS may not be provided while a beneficiary is

receiving hospice GIP and Hospice Inpatient Respite services.

Hospice is a State Plan service; therefore, hospice benefits must be fully utilized prior to HCBS

utilization in instances of potential duplication. The hospice and HCBS provider must coordinate the

delivery of care. All services delivered to hospice patients, regardless of provider, will be subject to

post-payment review.

Service Coordination and Communication

The hospice provider must ensure that a thorough interview process is completed when the

beneficiary elects the hospice benefit to identify all other Medicaid or other state and/or federally

funded program providers of care. This requirement applies to Medicaid beneficiaries as well as

dually eligible Medicare/Medicaid beneficiaries.

If at any time the hospice provider determines that HCBS are in place for the beneficiary, the

hospice provider must contact the HCBS provider(s) within two business days of the beneficiary

electing hospice to:

• coordinate the hospice plan of care

• coordinate scheduling of services, and

• initiate the Hospice-HCBS Coordination Form 160, complete the appropriate sections related

to the provision of hospice service, and send to the HCBS provider to complete the

appropriate sections related to the provision of HCBS.

• Provide the HCBS provider with a copy of the beneficiary’s hospice POC.

This allows for better communication with the beneficiary and family during the hospice admission

visit to outline the differences in services.

Hospice providers must submit the completed Hospice-HCBS Coordination form to the waiver case

manager within five (5) business days of completion and maintain a copy in the hospice provider’s

medical record for the beneficiary.

Should the beneficiary choose a new HCBS provider for services, the hospice provider must contact

the new HCBS provider within two days to:

• coordinate with the HCBS provider to develop the hospice plan of care

• coordinate with the HCBS provider in the scheduling of services

• initiate the Hospice-HCBS Coordination Form 160

• provide the HCBS provider with a copy of the beneficiary’s hospice POC

The hospice provider must obtain a copy of the beneficiary’s HCBS waiver person-centered service

plan and the HCBS provider must obtain copy of the beneficiary’s hospice POC. The hospice

provider must ensure the HCBS provider receives copies of any updated POC.

The hospice provider and HCBS provider must coordinate tasks and services as well as the time of

day that the beneficiary may receive visits from each provider’s direct care workers. Hospice and

HCBS providers must coordinate to ensure direct care service hours do not overlap. The hospice

provider and the HCBS provider shall instruct direct care workers that if they arrive at the home and

the other provider’s direct care worker is there, they shall report this to their respective providers

administration and leave the home. Any changes in scheduling for either of the providers must be

reported to the other to avoid duplication/overlap of services. Services provided at the same time by

hospice and HCBS providers are subject to recoupment.

In the event a beneficiary revokes or discharges from hospice, it is the hospice provider’s

responsibility to notify the HCBS direct care provider and waiver case manager within 5 business

days of such action.