Utah Medicaid Provider Manual, Hospice Care Services § 8-9.9

The hospice agency is responsible for notifying Medicaid whenever a member is

enrolled in hospice care, whenever a member is discharged from hospice care,

whenever a member moves into a nursing facility, intermediate care facility for

people with intellectual disabilities (ICF/ID), or freestanding inpatient hospice

facility, or whenever there has been a change in hospice agencies. When any of

these events occurs, the hospice agency must submit the following applicable

documents to Medicaid within 10 calendar days:

• A completed Hospice Admission Record Request, a copy of the signed

election statement, a copy of the initial plan of care when a member

becomes retroactively eligible for Medicaid and hospice care, and a copy

of the physician’s certification statement whenever a member is enrolled

in hospice care and for each election period thereafter,

• A copy of the completed Hospice Admission Record Request and

revocation statement whenever a member chooses to revoke hospice

benefits,

• A copy of the member’s written statement at the time of a change to a

different hospice agency, and

• A copy of the completed Hospice Admission Record Request indicating the

effective date of the discharge. If the discharge is “for cause, ” providers

must attach a copy of the written discharge order signed by the hospice

agency’s medical director. Providers must also send to DIH a written

summary describing the “for cause” reason of discharge and any

supporting documentation to show that the provider satisfied the

required steps prior to discharging the member from hospice care.