PA Lookup

The NC Medicaid (Medicaid) hospice benefit is a comprehensive set of services, identified and coordinated by a hospice interdisciplinary group (IDG). The IDG delivers medical, nursing, social, psychological, emotional, and spiritual services to enable physical and emotional comfort and support using a holistic approach to maintain the best quality of life for a terminally ill beneficiary, their family, and caregivers. The priority of hospice services is to meet the needs and goals of the hospice beneficiary, family, and caregivers with daily activities and to help the terminally ill beneficiary with minimal disruption to normal activities, in the environment that best meets the care and comfort needs of the beneficiary and unit of care.

The hospice IDG achieves this by organizing and managing a comprehensive care plan focused on coordinating care, services and resources to the beneficiary, caregivers, and family necessary for the palliation and management of the terminal illness and related conditions.

Only Medicare-certified and North Carolina licensed hospice agencies are eligible to participate as Medicaid hospice providers through the NC Division of Health Service Regulation (www.ncdhhs.gov). Each site providing hospice services must be separately licensed. The North Carolina Medical Care Commission has rulemaking authority for hospice. The statutes that apply to hospice agencies are General Statute 131E-200 through 207 and the licensure rules are under Title 10A of the North Carolina Administrative Code (10A NCAC 13K); (G.S. 131E, Article 9, 175-190) and administrative rules (10A NCAC Subchapter 14C).

A Hospice provider must have a contract with a nursing home or hospital if services are provided within those facilities.

Authorization Guidelines

The provider(s) shall submit the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in this policy.

The first (1st) benefit period and second benefit period (2nd) are both 90 calendar days. This begins the initial admission to Hospice service based on the original election date for the beneficiary.

At the first (1st) benefit period the hospice provider (s) shall create a prior approval request and upload the Election Statement which notifies NC Medicaid of the beneficiary election of hospice service. The PA request and election statement must be uploaded into NCTracks portal within six calendar days of the effective date of the beneficiary election of hospice service, according to 42 CFR 418.24.

The second (2nd) benefit period requires the entry of a PA request in to NCTracks, however, the election statement is not required at this benefit period The third (3rd) benefit period and each subsequent benefit period are 60 calendar days. The Hospice provider(s) shall create a prior approval request and upload all the following documents listed below online through the NCTracks Provider Portal for recertification:

• a. NC Medicaid Hospice Prior Approval Authorization Form (DMA3212);
• b. Hospice Recertification of Terminal Illness;
• c. Physician Plan of Treatment - Order for care and services;
• d. Face-To-Face Encounter
• e. Supporting clinical documentation (i.e. medical history, nurses’ IDG

notes, etc.), and assessment tools used to measure beneficiary status or decline. Hospice Assessment tool including, but not limited to, Functional Assessment Scales (FAST); Palliative Performance Scales;

New York Heart Association Functional Classification Tool (NYHA), Palmetto GBA Local Coverage Determinations.

Prior Approval (PA) requested for hospice services must be submitted on behalf of the medical director or beneficiary’s attending physician via NC Track at least ten calendar days before the end of the current benefit period.

Unit Value

unit of service = 1 day

Limits

First and second benefit periods are each 90 calendar days.

Third and each subsequent benefit period are 60 calendar days.

First-benefit-period PA request and election statement must be uploaded within six calendar days of the effective date of hospice election.

PA for third and subsequent benefit periods must be submitted at least ten calendar days before the end of the current benefit period.

Written certifications may be completed no more than 15 calendar days prior to the effective date of election.

Recertifications may be completed no more than 15 calendar days prior to the start of a subsequent benefit period. Face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the third benefit period recertification and every recertification thereafter.

Initial assessment must be completed within 48 hours after election of hospice care.

Comprehensive assessment must be completed no later than five calendar days after election of hospice care.

Medicaid room and board coverage in SNF/NF/ICF-IID applies when the Medicare hospice benefit is elected.

Exclusions

Medicaid shall not cover additional respite care services over and above the per diem amount contracted for hospice services. Attending and consulting physician services are not considered a hospice service and are instead covered under the Medicaid Physician Services program policies. A beneficiary who elects the hospice benefit waives rights to Medicaid coverage of other services that replicate hospice-covered services. Specifically, home health, durable medical equipment, and home infusion therapy are not allowed when they pertain to treatment of the terminal illness or related conditions, and drugs and biologicals pertaining to the terminal diagnosis are reimbursed to the hospice as part of the hospice per diem rather than separately, although Medicaid may reimburse the pharmacy directly for drugs used to treat conditions unrelated to the terminal illness. For beneficiaries under 21 years old, the waiver of curative services is not applicable, and concurrent care is available without requiring waiver of rights to cure- or treatment-related services for the terminal condition.

Diagnosis Requirements

The beneficiary must be terminally ill, meaning the beneficiary has a medical prognosis that life expectancy is 6 months or less if the illness runs its normal course.

Place of Service

The beneficiary’s primary private residence. An adult care home under a written agreement with the hospice provider. A hospice residential care facility or hospice inpatient unit. A hospital, nursing facility, or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) under a written agreement with the hospice provider

How to Submit

Please submit your request to Carolina Complete Health

• https://www.carolinacompletehealth.com/trillium-preauth.html

Resources

• Clinical Coverage Policy No: 3D
• Records Management and Documentation Manual

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