Va. DMAS Hospice Provider Manual ch. IV, Authorization For Services

Enrollment must be authorized by DMAS for reimbursement to be made for simultaneous

provision of services under the hospice Medicare or Medicaid benefit. Hospice Providers

must enter all hospice admissions and disenrollments directly into the AE&D portal for

FFS individuals enrolled in Hospice Hospice providers will no longer FAX the DMAS 421A

to DMAS. The Hospice provider must maintain the DMAS 420, 420A and 421A forms in

the individual’s record. Hospice enrollment cannot be completed without an active

Medicaid number.

For individuals enrolled in a managed care organization, please refer to and follow that

particular MCO’s hospice procedures for service authorizations.

The Request for Hospice Benefits form (DMAS 420), pages 1 and 2, must have all

physician signatures and dates before the DMAS 421A can be submitted to DMAS. If

there is no date for either physician’s signature, it is the hospice provider’s responsibility

to obtain current dated signatures certifying the individual is eligible. Please note

backdated signatures are not acceptable. Quality management/utilization reviews will be

conducted to ensure services are appropriate and all documentation requirements are

met.

A delay in enrollment shall place the hospice provider at risk of financial liability for

covered services provided after the election statement is signed. Prompt enrollment limits

the risk to the provider. The hospice provider cannot bill the individual for failure on the

provider’s part to obtain the required physician signatures and or failure to submit an

enrollment to DMAS. Verification of documentation will be conducted upon post payment

review.

In addition, the hospice provider must demonstrate respect for an individual’s rights by

ensuring an informed consent form, specifying the type of care and services that may be

provided as hospice care during the course of the illness, has been obtained for every

enrollee, either from the individual, or his or her representative. A representative is

defined as a person who is, because of the individual’s mental or physical incapacity,

authorized in accordance with state law to execute or revoke an election for hospice care

or to terminate medical care on behalf of the individual.

A determination of the appropriateness of Medicaid payment will be made for the initial

certification period, as well as each subsequent recertification period. With the exception

of instances where the individual or representative revokes during a previous benefit

period, subsequent periods of care do not have to be authorized, but shall be certified by

the physician, and the documentation of the physician's certification must be maintained

by the hospice provider. The initial date of authorization of services will not be made

retroactive prior to the date of the individual’s election of hospice.

Hospice is responsible for providing or arranging for all services pertaining to the terminal

illness. DMAS will perform quality management/utilization reviews to determine if the

services were provided by the appropriate provider and to ensure services provided to

individuals enrolled in Medicaid are medically necessary, appropriate, and that all

certification and recertification requirements are met.