S.D. Medicaid Billing and Policy Manual, Hospice Services, Reimbursement and Claim Instructions

Timely Filing

South Dakota Medicaid must receive a provider's completed claim form within 6 months following the

month the service was provided. Requests for reconsiderations will only be considered if they are

received within the timely filing period or within 3 months of the date a claim was denied. The time limit

may be waived or extended by South Dakota Medicaid in certain circumstances. Providers should refer

to the General Claim Guidance manual for additional information.

Third-Party Liability

Medicaid recipients may have one or more additional source of coverage for health services. South

Dakota Medicaid is generally the payer of last resort. Providers must pursue the availability of third-party payment sources and should use the Medicare Crossover or Third-Party Liability billing

instructions when applicable. Providers should refer to the General Claim Guidance manual for

additional information.

Reimbursement

Hospice services are reimbursed at the lesser of billed charges or the applicable rate on the Hospice

fee schedule. Reimbursement is based on the level of hospice care and intensity of services provided

each day to the recipient. The maximum reimbursement rate for routine home care is based on the

length of time the recipient is in hospice care on a cumulative basis without a 60-day break in stay. If

readmission occurs after 60 days, the cumulative day calculation starts over.

• Day 0 to 60 = Routine high rate on fee schedule

• Days 61+ = Routine low rate on fee schedule

If a recipient is a live discharge from hospice and is then readmitted to hospice within 60 days of being

discharged, that recipient’s days from his or her initial admission will count towards their total day count.

For example, if a recipient is discharged on day 55 and readmitted 5 days later, upon readmission their

first day will be considered day 56. If a recipient is a live discharge from hospice and is not readmitted

until more than 60 days after discharge the count of days will start over at 1 upon readmission.

Services Included in the Fee Schedule Rate

The applicable fee schedule rate is considered reimbursement for the cost of all covered services

related to the treatment of the recipient’s terminal illness, including palliation and management of

symptoms of the terminal illness, payment for the administrative and general supervisory activities

performed by the medical director or a physician member of the interdisciplinary team. These activities

include participation in establishment of care plans, supervision of care and services, periodic review

and updating of care plans, and establishment of governing policies. These items are not separately

reimbursable.

Physician Services Unrelated to the Terminal Illness for Recipients Age 21 and Older

A hospice may be reimbursed for physician services unrelated to the recipient’s terminal illness, such

as direct patient care services furnished to individual patients by a physician employed by the hospice

and for physician services furnished under arrangements made by the hospice. The only services that

may be billed by an attending physician are the physician’s face-to-face professional services. The

reimbursement for physician services is in addition to the daily rates. Costs for services such as lab or

x-rays done in relation to the terminal illness may not be included on the attending physician’s claim.

Covered physician services are paid at the current Medicaid rate for physician or other licensed

practitioners. Volunteer physician services are not covered. Please refer to the Non-Covered Services

section for more information.

Services of an independent attending physician are not part of the hospice care and not reimbursable

to a hospice. An independent physician must bill South Dakota Medicaid directly when providing

physician services unrelated to the recipient’s terminal illness.

Inpatient Care Days Limits

Payments for inpatient care days will be limited according to the number of inpatient care days

furnished to medical assistance recipients by the hospice in a year. The maximum number of payable

inpatient respite and general inpatient days may not exceed 20 percent of the total number of hospice

care days provided to all Medicaid recipients by the hospice. If the maximum number of days exceeds

twenty percent of total days, an adjustment will be made to pay the excess days at the routine home

care rate and the difference will be recovered from the hospice provider. The limitation on inpatient care

days does not apply to recipients diagnosed with acquired immunodeficiency syndrome (AIDS).

Room and Board

If a recipient is receiving routine home care or continuous home care in a skilled nursing facility, ICF-

IID, or swing bed, a room and board payment equal to 95 percent of the Medicaid rate will be made to

the hospice provider. The facility is paid by the hospice provider pursuant to their written agreement as

required by 42 CFR 418.112.

The hospice may not negotiate a room and board rate with the long-term care facility with the exception

of payment for private room accommodations. No additional payment will be made to the hospice for

negotiated private room rates. No retroactive adjustments are available for charges in the Medicaid rate

made subsequent to the payment of room and board. Adjustments may be made to correct errors in

billing.

Post-Eligibility Treatment of Income

If a recipient has a recipient liability, the amount will be shown on a remittance advice. The hospice is

responsible for collection of this amount from the recipient. The hospice may make arrangements with

the long-term care facility to collect the recipient liability. The department will not reimburse the hospice

for any uncollected recipient liability. Refer to the Billing a Recipient Manual for additional information.

Claim Instructions

Hospice Services

Claims for Hospice services must be submitted on the UB-04 claim form or via an 837I electronic

transaction. Detailed claim instructions are available on our website.

Physician Services Unrelated to the Terminal Illness

Physician services unrelated to the terminal illness must be submitted on a CMS 1500 form or 837P at

their usual and customary charge. Detailed claim instructions are available on our website. Hospice

employed physician services are included in the hospice services and are not separately billable.