5160-56-03.3 Hospice services: reporting requirements.

(A) The purpose of this rule is to enable recording of the hospice service span of every individual receiving medicaid hospice services in accordance with Chapter 5160-56 of the Administrative Code, even if the individual is covered by third-party insurance, which includes medicare.

(B) In this rule, the following definitions apply:

(1) "Beginning date of service" means the first date on which a provider delivers hospice services to an individual.

(2) " Individual" means a person who:

(a) Is eligible for medicaid;

(b) Has satisfied applicable spenddown; and

(c) Has elected to receive the hospice benefit.

(3) " Individual election date" means the date on which a individual elects, in writing, to receive hospice services in accordance with Chapter 5160-56 of the Administrative Code.

(4) "Ending date of service" means the date on which a provider stops delivering hospice services to the individual because of revocation of the medicaid hospice benefit, discharge from the hospice benefit, change by the individual of the designated hospice, or death of the individual in accordance with Chapter 5160-56 of the Administrative Code.

(5) "Hospice service span" means the period of time, delimited by the beginning date of service and the ending date of service, during which an individual receives hospice services from a hospice provider in accordance with Chapter 5160-56 of the Administrative Code.

(6) "Interactive Voice Response system" or "IVR system" means the telephone-based system maintained by ODJFS that gives authorized entities access to data such as medicaid eligibility, claim status, payment status, prior authorization, drug and procedure codes, and provider information.

(7) "Oral physician certification date" means the date on which an oral physician certification statement that the individual is terminally ill is obtained in accordance with Chapter 5160-56 of the Administrative Code.

(8) "Written physician certification date" means the date on which a written physician certification statement that the individual is terminally ill is obtained in accordance with Chapter 5160-56 of the Administrative Code.

(C) Each provider of hospice services shall enter the following information into the IVR system:

(1) Within thirty days after the beginning date of service, the provider of hospice services shall enter:

(a) The hospice provider number;

(b) The individual's recipient identification number (also referred to as the medicaid billing number) as shown on the individual's medicaid card;

(c) The beginning date of service;

(d) Either:

(i) The written physician certification date or

(ii) The oral physician certification date;

(e) The individual election date; and

(f) At least one but not more than three terminal diagnosis codes for the individual.

(2) No earlier than the beginning date of service and no later than thirty days after the ending date of service, the provider of hospice services shall enter:

(a) The written physician certification date;

(b) The ending date of service; and

(c) The date of death, if applicable.

(3) No earlier than the beginning date of service and no later than thirty days after the ending date of service, the provider of hospice services may change or update:

(a) The oral physician certification date;

(b) The written physician certification date;

(c) The individual election date;

(d) Not more than three terminal diagnosis codes for the individual, so long as at least one diagnosis code remains entered in the IVR system;

(e) The ending date of service; or

(f) The date of death.

(D) The information specified in paragraph (C) of this rule shall be submitted only through the IVR system in accordance with the requirements of that system.

(E) The information specified in paragraph (C) of this rule shall be submitted for all individuals receiving medicaid hospice services, without regard to the payer.

(F) No provider of hospice services shall be entitled to payment on a claim before the information specified in paragraph (C)(1) of this rule has been submitted.

Effective: 4/1/2015
Five Year Review (FYR) Dates: 12/19/2014 and 04/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.70
Prior Effective Dates: 9/1/07