Tex. HHSC Medicaid Hospice Provider Manual § 4100

Revision 11-1; Effective May 11, 2011

A provider must have a HHSC Medicaid contract to receive Medicaid payment for hospice services. HHSC pays the Medicaid hospice provider at periodic intervals, depending on when the provider bills for approved services. Payments are based on the hospice care setting applicable to the type and intensity of hospice services provided to the Medicaid hospice recipient for that day.

HHSC Provider Claims Services authorizes hospice services, according to department, state and federal regulations, for contracted providers that furnish Medicaid services to HHSC consumers. Provider Claims Services does not develop program policy, but is responsible for applying established policy when performing the authorization for reimbursement function.

Payment for hospice services is controlled by receipt of information. Payment will not occur until the following conditions are verified:

the Medicaid Eligibility (ME) specialist or the Social Security Administration (SSA) certifies that the recipient is Medicaid eligible for the hospice program;

the Texas Medicaid & Healthcare Partnership (TMHP) receives Form 3071, Individual Election/Cancellation/Update;

TMHP receives Form 3074, Physician Certification of Terminal Illness;

if applicable, Minimum Data Set (MDS) assessment is received by TMHP; and

if applicable, the Level of Need (LON) Assessment.

Medicaid hospice providers have the option of submitting the hospice eligibility forms, Form 3071 and Form 3074, through a web-based, online system called Long Term Care (LTC) Online Portal. This new system has a web portal interface to submit forms, corrections, status inquiries and retrieve status reports. Providers interested in the web-based portal should contact TMHP at 800-626-4117.

Providers who choose to submit paper eligibility forms must submit them to:

Texas Medicaid & Healthcare Partnership

TMHP LTC Unit

P.O. Box 200765

Austin, TX 78720-0765

Eligibility forms are validated when received at TMHP. If any deficiencies are noted, the document is returned to the provider with an explanation. The hospice provider will not receive payments until Medicaid eligibility is verified and Form 3071 and Form 3074 are received at TMHP. All eligibility forms are processed according to the date they are received. Forms returned to the provider for a deficiency and then resubmitted are processed according to the new receipt date.

TMHP processes hospice forms in 14 workdays for individuals who have Medicaid eligibility. Only individuals who have Medicaid eligibility can be seen in the electronic Claims Management System (CMS) Medicaid Eligibility Services Authorization Verification (MESAV) file. Forms received for individuals who have pending eligibility are suspended in a pending file at HHSC until HHSC has been notified that the individual is eligible for hospice services. Direct questions about service authorizations or forms that cannot be seen on CMS to TMHP at 800-626-4117.

All payments under the Medicaid Hospice Program are only for services related to the treatment of an individual's terminal illness. HHSC continues to pay through other service programs for services not related to the treatment of a individual's terminal illness. Exception: In accordance with Section 2302 of the Patient Protection and Affordable Care Act of 2010 (P.L.111-148), individuals under 21 years of age are not required to waive Medicaid payment for treatments related to the terminal illness.