Wyo. Medicaid Institutional Provider Manual § 16.1.1

Members requesting coverage of hospice services under Wyoming Medicaid are locked-in to the hospice

for all care related to their terminal illness. All services and supplies must be billed to the hospice

Provider, and the hospice Provider will bill Wyoming Medicaid for covered services. For more

information regarding Member lock-in (see Section 4.4 Member Lock-In).

Providers must complete and submit the Wyoming Department of Health Hospice Benefit Election Form

(see Section 16.1.1.1 Hospice Benefit Election Form) as this is the only form that will be accepted.

The Hospice Benefit Election Form and physician certification of terminal illness must be mailed or

emailed to Provider Services (see Section 2.1 Quick Reference) and faxed or emailed to the Long Term

Care Unit (see Section 2.1 Quick Reference).

o Hospice services must be requested as soon as the individual is considered to be terminal.

The form must be submitted timely to alleviate individuals not being approved for services

and claims being denied. Providers not completing the process timely will not be approved

for claim submission past timely filing.

o If an individual is approved for Medicaid after they start receiving hospice services, the

Medicaid Hospice Benefit Election Form (see Section 16.1.1.1 Hospice Benefit Election Form)

must be submitted with the physician certification of terminal illness as soon as the

individual is determined eligible. The Medicare Hospice Election form must be attached. The

date of the Medicaid Hospice Benefit Election Form must be the date of the Medicare

Election form. This form must be submitted to the Medicaid LTC Worker and Acentra Health.

Information is below.

o When the Member elects hospice services and is residing in a nursing facility, the hospice

Provider must complete and submit the Hospice NH Room & Board Request Form (see

Section 16.1.1.2 Hospice NH Room & Board Request Form) to be assigned a rate for revenue

code 0658. This form must be submitted to the Medicaid LTC Worker and Acentra Health.

Information is below.

The Medicaid Hospice Benefit form, physician certification of terminal

illness, and if appropriate, the Hospice NH Room and Board Request

form must be submitted to the Long Term Care Eligibility Unit at

ltcunit@wyo.gov and sent to Acentra Health at

WYProviderOutreach@acentra.com or the following address:

Wyoming Medical Fiscal Agent

Attn: Provider Services

P.O. Box 1248

Cheyenne, WY 82003-1248

If forms are not submitted, claims can be denied.

Submitting the Hospice Benefit Election Form does not guarantee the

Member is eligible for hospice benefits. The Long Term Care Unit

needs to be provided the Hospice Election form before they can make

a final eligibility determination.