Medicaid - DME - Guidelines and coverage policies



1.DMEPOS Program coverage areas include parenteral and enteral nutrition (PEN), medical foods and oxygen and oxygen equipment; all of which must meet the definition of durable medical equipment, a prosthetic device, an orthotic device, or disposable medical supply.

2.Durable Medical Equipment (DME) of a medical nature, needed as a result of a medical condition, and which lasts a considerable time without significant deterioration and appropriate for use within the home, is covered by the Division of Health Care Financing and Policy (DHCFP) and Nevada Check Up (NCU) for eligible recipients. Equipment repairs, or replacement requires medical documentation and is subject to limitations of model, cost and frequency, which are deemed reasonable by the program.

3.Disposable medical supplies are covered by the DHCFP and NCU for eligible recipients only if they are necessary for the treatment of a medical condition and would not generally be useful to a person in the absence of an illness, disability or injury.

4.All DMEPOS products and services must be medically necessary, safe and appropriate for the course and severity of the condition, using the least costly and equally effective alternative to meet the recipient’s medical needs.

5.Deluxe equipment will not be authorized when it is determined a standard model will meet the basic medical needs of the recipient. The recipient must have a medical need for each component of the item(s) requested. This includes accessory items and features not included in the standard models of the product.

6.Equipment which the program determines is principally for education or rehabilitation will not be approved.

7.Refer to Appendix A of this Chapter for non-covered services, and for special coverage considerations that are based on medical necessity outside of the DMEPOS Program or that is considered under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Healthy Kids Program.

8.Refer to Appendix B of this Chapter, for Coverage and Limitation Policies regarding specific coverage information, qualifications, documentation requirements, and miscellaneous information.

9.Refer to the Provider Type 33 DMEPOS Fee Schedule for specific item coverage under the DMEPOS program. Access

10.The DHCFP does not reimburse for items that are the same or similar to items that the recipient has already acquired, such as but not limited to back-up equipment, unless allowed in the specific policy for that item. Duplicate items intended to be used within the same span of time are not considered medically necessary.

11.Individuals deemed eligible for Nevada Medicaid or NCU and who have ownership of existing equipment from any prior resource must continue using that equipment. Existing equipment, regardless of who purchased it, must be identified, including the estimated date of purchase or age of equipment, and medical documentation showing evidence of need for replacement. All documentation must be submitted with a prior authorization request.

12.Some items not covered under the DMEPOS Program may be covered under other Medicaid programs such as Pharmacy, Audiology, or Ocular programs. Additional resources may be available through other agencies or through waiver programs for items not covered under the DMEPOS Program or by the Medicaid State Plan.


1.All DMEPOS providers must be licensed through the Nevada State Board of Pharmacy (BOP) as a Medical Device, Equipment, and Gases (MDEG) supplier, with the exception of a pharmacy that has a Nevada State Board of Pharmacy license and provides DMEPOS. Once licensed, providers must maintain compliance with all Nevada BOP licensing requirements. Reference Medicaid Services Manual (MSM) Chapter 100 – Medicaid Program for further information on enrollment and provider responsibilities. Also refer to the Enrollment Checklist posted on the following website at:

2.Suppliers of products covered under the Medicare Part B program are required to be enrolled in the Medicare Part B program in order to provide those services to Medicare and Medicaid dually eligible recipients. This includes obtaining and maintaining the Centers of Medicare and Medicaid Services (CMS) required accreditation and surety bond.

3.Potential providers who are not enrolled with the Medicare Part B program and who will not be supplying products covered under the Medicare Part B program to

individuals eligible for Medicare are required to provide a statement on/with their application that requests a waiver of the requirements for Medicare Part B enrollment. This statement must indicate that they do not service Medicare-eligible individuals and include a listing of the products they plan to supply.

4.A Medicaid-contracted DMEPOS provider may be reimbursed for services rendered to Medicaid eligible recipients when provided in accordance with established policies, guidelines and timeframes.

5.The provider is responsible for ensuring the equipment is appropriate for the recipient and the recipient’s residence prior to billing the DHCFP.

6.The provider is responsible for providing a manufacturer’s invoice for certain items, where no rate has been established.

7.The DMEPOS provider must comply with additional requirements as specified throughout this Chapter and its Appendices, Medicaid Services Manual (MSM) Chapter 100, the Provider Type (PT) 33 DMEPOS Fee Schedule, the Provider Billing Manual, and DMEPOS Billing Guidelines.


The eligible Nevada Medicaid or NCU recipient and/or their authorized representative will:

1.Make and keep appointments necessary for securing medical services/equipment;

2.Present current verification of Nevada Medicaid or NCU eligibility;

3.Present any forms or identification necessary to utilize other health insurance coverage;

4.Contact and return to the provider of services/equipment for any necessary adjustment within the time allotted for such adjustments;

5.Maintain the equipment provided by routinely cleaning and caring for the devices according to user information and supplier’s guidance. Provide safe, secure storage for item(s) when not in use to protect item(s) from loss or theft;

6.Not misuse, abuse or neglect purchased or rented item(s) in a way that renders the item(s) unsafe or non-usable;

7.Return all rented equipment to the DMEPOS provider when no longer being used, or upon the DME provider’s request. Failure to return rented equipment could result in a recipient’s financial responsibility for the retail price of the rented equipment, even if the equipment is lost/stolen, the recipient has moved, or they are no longer eligible for Nevada Medicaid/NCU.

8.Comply with additional requirements as specified throughout this Chapter and its Appendices and MSM Chapter 100.


A.Supplier/provider records must substantiate the medical necessity for all DMEPOS items dispensed to recipients. The following describes the requirements for specific types of documentation associated with DMEPOS.


a.All DME items, Prosthetics, Orthotics, or Disposable Supplies (POS) dispensed must have an order/prescription from the treating physician or practitioner, (To determine included practitioners, refer to MSM, Chapter 600 – Physician’s Services), such as a Physician’s Assistant (PA), or Advanced Practitioner of Nursing (APN), when within their scope of practice and in accordance with federal and state laws governing  that entity, prior to dispensing the item.

In accordance with the Patient Protection and Affordable Care Act (PPACA) (The Affordable Care Act) of 2010 (Public Law 111-148), all orders for DMEPOS items, whether verbal or written, must be incidental to a physician-documented face-to-face encounter between the recipient and the prescribing physician/practitioner (as allowed by The Act) within 30 days prior to the start date of the order. The encounter must be relevant to the need for the prescribed DMEPOS.

Refer to Appendix B of this Chapter for additional order requirements on specific products.

General standards of care/practice mandate that if an order is not clear, a clarification of the order must be obtained from the ordering practitioner prior to acting on it.

b.Verbal Orders:

1.Verbal orders from the prescribing physician/practitioner may be accepted for DMEPOS items that do not require prior authorization by the DHCFP (except when Medicare is primary and Medicaid co- payment will be requested, and Medicare requires a written order for that item prior to delivery). Refer online to the DME MAC Jurisdiction D Supplier Manual, Chapter 3 – Documentation Requirements, for a current listing of those items at:

2.The verbal dispensing order must include:

a.A description of the item;

b.The recipient’s name;

c.The physician’s name;

d.The start date and length of need of the order; and

e.Additional information sufficient to allow appropriate dispensing of the item.

3.Suppliers must maintain written documentation of the verbal order and, if the verbal order is used for dispensing the item, the supplier must obtain a detailed written order prior to billing the DHCFP.

c.Written Orders:

1.Written orders are acceptable for all transactions involving DMEPOS and must be obtained prior to submitting a prior authorization for any DMEPOS items. Written orders may take the form of a photocopy, facsimile image, electronically maintained, or original “pen-and-ink” document.

2.All written orders must, at a minimum:

a.Clearly specify the start date of the order;

b.Include the length of need;

c.Be sufficiently detailed, including all options or additional features that are needed to meet the recipient’s needs. The description must be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number; and

d.Be signed and dated by the treating physician/practitioner. Signature includes computer signature and pen and ink, no signature stamps allowed.

3.Certain items require additional elements in the written orders, as follows:

a.If the written order is for supplies that will be provided on a periodic basis, the written order must include appropriate information on the quantity used, frequency of change, and duration of need. (For example, an order for surgical dressings might specify one 4x4-hydrocolloid dressing that is changed one to two times per week for one month or until the ulcer heals).

b.If the written order is for an item such as, but not limited to, enteral formula, oxygen, etc., the order must specify the name of the product, concentration (if applicable), dosage, frequency and route of administration, and duration of infusion (if applicable).

c.Custom-fabricated items must be clearly indicated on the written order that has been signed and dated by the prescribing physician/practitioner.

4.There are additional specifications for orders for certain items, such as, but not limited to, Power Mobility Devices (PMDs). Refer to Appendix B for details.

5.The detailed description of the item(s) may be completed by an employee of the ordering physician/practitioner; however, the prescriber must review the detailed description and personally indicate agreement by signing and dating the order.

6.Medical necessity information (such as the most current appropriate diagnosis code(s) (ICD) diagnosis code, narrative description of the recipient’s condition, abilities, and limitations) is not in itself

considered to be part of the order although it may be put on the same document as the order.

d.New Orders Are Required When:

1.There is a change in the order of a specific DMEPOS item;

2.There is a change in the resident’s condition that warrants a change in the order, a change in the treating physician/practitioner, or DMEPOS supplier;

3.An item is replaced for any reason; or

4.An ongoing unchanged order continues to be medically necessary one year after the original order (orders are only valid for up to one year, unless documented with a shorter length of time).


The detailed product description must contain the Healthcare Common Procedure Coding System (HCPCS) code, manufacturer, make and model, and the provider’s/supplier’s usual and customary charge for each item supplied. The warranty information must also be included. This may be completed by the provider/supplier but must also be signed and dated by the physician.


A POD is a supplier’s delivery receipt, which is dated and timed.

NOTE: Item(s) ordered must be delivered within 120 days of the date of the order.


The recipient’s medical records must contain sufficient documentation of the recipient’s medical condition to substantiate the necessity for the type and quantity of items ordered and the frequency of the use or replacement. The information must include the recipient’s diagnosis and other pertinent information, including but not limited to: duration of recipient’s condition, clinical course (deteriorating or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. The records must include physician’s office records, hospital, nursing home or home health records, records from other professionals including but not limited to: nursing, physical and occupational therapists, prosthetists and orthotists, although

medical necessity for item(s) requested must be stated by the prescribing physician/practitioner.


When Medicare is the primary payer, for all items requiring an ADMC (refer online to the DME MAC Jurisdiction D, Supplier Manual, Chapter 9). The ADMC determination must be submitted to the Quality Improvement Organization (QIO)- like vendor at the same time the prior authorization is submitted.


1.The provider must obtain the required documentation in a timely manner as described under each section listed previously.

2.The provider must maintain records at the physical location of their business for each item billed to, and paid by, the DHCFP for at least six years from the Remittance Advice (RA) date. At a minimum, this includes the original signed order/prescription, all supporting medical documentation, and proof of delivery.

3.The provider must maintain records in a readily accessible location and, for audit and investigation purposes, to make available upon request by Medicaid staff or its contractors, all supporting information related to prior authorizations, dispensed items, and/or paid clams for DMEPOS items.


Items identified in the DMEPOS Fee Schedule with a rental and purchase option require prior authorization to determine if the recipient’s needs justify rental or purchase based on the item prescribed, the individual’s anticipated length of need and prognosis (as determined by the prescriber) and cost effectiveness to the DHCFP and NCU.


1.In addition to all other requirements and qualifications for specific products, if the DMEPOS Fee Schedule allows a rental option, a device may be rented when:

a.the anticipated length of need (per physician’s/practitioner’s order) is short term (six months or less) and rental would be more cost effective than purchase;

b.a temporary trial period is required for the item according to Medicaid’s policy;

c.the item is only available as a rental per the DMEPOS Fee Schedule; or

d.a temporary rental is needed while a recipient-owned like item is being repaired.

2.During a rental period, rental rates include all supplies and accessories necessary to render the equipment useable and safe, delivery and set up services, education and training for recipient and family, routine maintenance and servicing (such as testing, cleaning, regulating and checking equipment), repairs, non-routine maintenance and servicing (such as breaking down sealed components and performing tests which require specialized equipment and skills of a technician), and replacement of items. These services are the responsibility of the owner, the DMEPOS supplier.

3.Throughout any rental period, there must be an active physician’s/practitioner’s order for ongoing use, the prior authorization effective dates are still applicable, and there is a continued medical need for the item. The DMEPOS supplier must contact the recipient or their representative within five business days prior to each billing cycle to verify the rented item is still medically necessary, in working condition, and being used by the recipient (contact does not include system generated correspondence). Verification must be documented and maintained in the DMEPOS supplier’s records and be accessible for audits.

4.Rent-to-Purchase Option:

a.The DHCFP allows rental of certain DMEPOS items up to the provider’s Usual and Customary Charge (UCC) for purchase, or the maximum Medicaid allowable purchase price of the item; whichever is less.

b.Unless the item is identified by Nevada Medicaid as a rental only, once the total cumulative rental payments have reached the lower of UCC or maximum Medicaid allowable purchase rate, the item is considered purchased in full and recipient-owned.

c.The provider shall automatically transfer the title for the equipment to the recipient. Providers are not to submit prior authorization to transfer titles. Providers are also not to submit prior authorizations coded as a purchase after the lower of UCC or Medicaid allowable purchase rate is reached. No rental or purchase payments will be made for the remaining reasonable useful lifetime of the device (usually not less than five years (60 months)). The provider’s records must include the date the title was transferred to the recipient.

d.When an item was new at the time of issuance, and it is later determined the recipient will need the item long term, rental payments will be applied toward the total purchase rate (either the provider’s UCC or the Medicaid allowable). Refer to “Purchase Used Equipment Option” in Section 1303.

e.Equipment that was not new at the time of issuance, such as items from the provider/supplier rental fleet, supplied as a temporary short term rental item must be replaced with new equipment as soon as it is identified the recipient will need the device long term (no later than in the sixth month of rental). Payments made on rental fleet-type items will not be applied to the purchase price of a new item. Purchase or transfer of titles to recipients when the used equipment is from a rental fleet is not allowed.

f.For this option, non-routine maintenance and servicing or repairs may be covered for service dates after the item is owned by the recipient; no sooner than the month following the last rental month.

5.Rental Only Option:

a.Certain items are identified by Nevada Medicaid as a rental only. For these items, a monthly rental will be allowed as long as the recipient continues to meet all qualifications and requirements, and the recipient continues to use the device.

b.For this option, the DMEPOS supplier retains ownership of the equipment, regardless of the length of rental. As the owner, the DMEPOS supplier is responsible to ensure the equipment remains in safe working condition for the reasonable useful lifetime of the device. The rental rates include all supplies and accessories, repairs including routine and non-routine maintenance and servicing, and replacement of items when needed.

1.Purchase New Equipment Option:

a.Certain products are identified by Nevada Medicaid in the DMEPOS Fee Schedule with a purchase option for new equipment, or can only be purchased, such as disposable supplies and custom-made items which can only be used by that recipient. These will be considered for purchase when, in addition to all other requirements and qualifications for a specific item/device:

1.the anticipated length of need (per physician’s order) is long term (more than six months); and

2.the provider will be supplying a new device/item to the recipient; or

3.the item is only available for purchase.

2.Purchase Used Equipment Option:

a.Certain products are identified by Nevada Medicaid with a purchase option for used equipment. When an item was new at the time it was dispensed to a recipient for rental purposes, and prior to billing the third month of rental, it is determined the item will be needed indefinitely, the DHCFP may purchase the item for the recipient for ongoing use. The DHCFP does not purchase used equipment from the provider’s inventory of rental items used for re-issuance to same or multiple persons over time (rental fleets, etc.).

b.The DHCFP will only purchase used equipment when, in addition to all other requirements and qualifications for the item:

1.the recipient meets the criteria for purchase of new equipment;

2.the item was new when placed in the recipient’s use and has been used for less than three months; and

3.the item is currently being used by the same recipient during a trial period and it has been determined the length of need will now be indefinite.

c.A prior authorization must be submitted to request purchase of a used item, with all supportive medical documentation to show the date the item was initially issued to the recipient and that the recipient continues to have an ongoing need for the item.


A.Prior authorization is a review conducted by the Quality Improvement Organization (QIO)-like vendor’s medical professionals who review the prior authorization form and any additional information submitted to evaluate medical necessity, appropriateness, location of service, and compliance with the DHCFP’s policy, prior to delivery of service. Reference the MSM, Chapter 100 and the general Billing Manual for detailed information on prior authorizations and Medicaid eligibility for all providers at:


a.Prior authorizations must be completed and submitted by a current Medicaid provider (requestor), and the approval must be received, prior to delivery of services. The exception to this is if the recipient is determined eligible for Medicaid retroactively or if number four of this section applies.

b.A prior authorization is required for most durable medical equipment, prosthetics, orthotics, and oxygen.

c.A Medicaid provider may submit the prior authorization electronically using the QIO-like vendor’s on-line prior authorization system or may fax or mail the prior authorization to the QIO-like vendor. For more information, refer to the prior authorization section posted at:

d.Requestors must submit a prior authorization with the most appropriate HCPCS code available and may not unbundle items included in the HCPCS code description. If an item has a designated code available, the miscellaneous code cannot be used. Providers may contact the Medicare Pricing, Data Analysis and Coding (PDAC) contractor, or the DME MAC for guidance on correct coding.

e.Documentation requirements are the same regardless of which mode of submission is used (e.g. the on-line prior authorization system, faxed, or mailed). Documentation submitted for consideration of the request must include the physician’s order and must clearly support coverage qualifications and recipient’s medical need for the equipment. Failure to provide all of the supporting medical documentation in its entirety, and within the required timeframes, will result in a denial of the prior authorization request, regardless of mode of submission.

f.Unless otherwise stated in policy, a prior authorization may be submitted to request authorization to exceed established quantity limitations when the medical documentation supports medical necessity for the increased quantity or frequency.

2.Review Consideration:

a.In addition to the specifications mentioned previously, for reviewing the prior authorization, products and services must be medically necessary, safe and appropriate for the course and severity of the condition using the least costly equally effective alternative to meet the recipient’s needs.

b.The recipient must have a medical need for, and the requested item must be suitable for use within the home. Consideration will also be based on the recipient’s additional use of the item for the conditions in each of the environments the recipient is likely to encounter in their daily routines, such as, but not limited to: attending school, work, and shopping. This information must be included in the supportive documentation submitted with the prior authorization.

c.For durable medical equipment, prosthetics, orthotics, and disposable medical supplies and appliances where coverage and limitation policies have not been established within this Chapter or its Appendices, the DHCFP may defer to DME MAC Jurisdiction D, Local Coverage Determination (LCD) and policy articles for coverage and limitation criteria. These can be accessed at: The item must meet the definition of durable medical equipment, prosthetic, orthotic, or disposable medical supply and must be necessary to meet the medical needs of the recipient, and must be part of the prescribing physician’s/practitioner’s Plan of Care (POC).

d.The DHCFP has the option of requesting an Independent Medical Evaluation (IME) to determine the recipient’s limitations and abilities to support medical necessity.

3.Prior Authorization Requirements for Third Party Liability (TPL) and Medicare Crossovers:

a.Refer to MSM, Chapter 100, for more information on TPL, and Medicare Crossovers and the requirements for securing prior authorizations.

4.Prior Authorization Emergency Situations:

a.In an emergency situation, when an order is received by the supplier after the QIO-like vendor working hours or over weekends or State holidays, dispensing of a 72-hour supply of those DMEPOS items that require prior authorization will be allowed only when:

1.A delay of 24 hours of treatment could result in very severe pain, loss of life or limb, loss of eyesight or hearing, injury to self, or bodily harm to others; and

2.The treating physician/practitioner indicates the most current appropriate diagnosis code(s)/ICD code on the prescription that supports the use of the emergency policy.

b.The provider/supplier must submit the prior authorization the next business day with all required supportive documentation. The documentation must include proof of the date and time the order was received by the supplier and documentation to support both 1303.4(a.)(1.) and (2.).

5.DMEPOS Specific Prior Authorization Forms:

All forms must be completed and submitted by a current Medicaid  provider. Forms used must be the most current version.

a.All Forms and Form Release Memorandums or instructions may be accessed at the DHCFP’s website: The instructions provide detailed guidance on form completion requirements.

b.Specific DME prior authorization forms are found on the QIO-like vendor’s website: All DMEPOS items that require prior authorization must be requested on these forms and submitted electronically, by fax or by mail to the QIO-like vendor for approval.

c.Usage Evaluation – For Continuing Use of Bi-Level and Continuous Positive Airway Pressure (BIPAP and CPAP) Devices use the form, found on the QIO-like vendor’s website. This form may be completed and submitted for continuing usage of BIPAP or CPAP devices.

d.Mobility Assessment for Mobility Devices, Wheelchair Accessories and Seating Systems, form found on the QIO-like vendor’s website. This form must be submitted for all mobility devices, wheelchair accessories and seating systems.

6.Denied Prior Authorization Requests:

a.There are various processing levels associated with prior authorization requests which do not support medical necessity. These may include, but are not limited to: a contact to the provider by the QIO-like vendor, a system generated technical denial, a system generated denial or reduction of services, a provider-requested reconsideration, a provider-requested peer-to-peer review with the physician. For specific information on time limits and an explanation of each, refer to the general Billing Manual for all providers at:

b.If a prior authorization request is denied or reduced, the provider and recipient will be sent a Notice of Decision (NOD) with a citation/reason to

provide a general explanation of the denial. The provider may request consideration of the denial by submitting additional supportive information and requesting a “Reconsideration” in writing.

c.If a reconsideration is not appropriate or is also denied, the recipient may be entitled to request an appeal or hearing. Refer to MSM Chapter 3100 – Hearings.


1.Coverage and limitations are explained throughout this Chapter, including its appendices. Appendix B details coverage qualifications, prior authorization documentation requirements, and limitations for specific items.

2.Refer to the Nevada Medicaid Provider Type 33 – DME Fee Schedule posted at: for covered services. The Fee Schedule identifies covered services/items (listed in alpha-numeric order according to HCPCS code), and rates. Codes are updated yearly. Codes not included in the fee schedule after the yearly update are considered non-covered.

Provider signature requirements - Medical record

Signature Requirements

In the content of health records, each entry must be authenticated by the author. Authentication is the process of providing proof of the authorship signifying knowledge, approval, acceptance or obligation of the documentation in the health record, whether maintained in a paper or electronic format accomplished with a handwritten or electronic signature. Individuals providing care for the patient are responsible for documenting the care. The documentation must reflect who performed the service.

a. The handwritten signature must be legible and contain at least the first initial and full last name along with credentials and date. A typed or printed name must be accompanied by a handwritten signature or initials with credentials and date.

b. An electronic signature is a unique personal identifier such as a unique code, biometric, or password entered by the author of the electronic medical record (EMR) or electronic health record (EHR) via electronic means, and is automatically and permanently attached to the document when created including the author’s first and last name, with credentials, with automatic dating and time stamping of the entry. After the entry is electronically signed, the text-editing feature should not be available for amending documentation. Example of an electronically signed signature: “Electronically signed by John Doe, M.D. on MM/DD/YYYY at XX:XX A.M.”

c. A digital signature is a digitized version of a handwritten signature on a pen pad and automatically converted to a digital signature that is affixed to the electronic document. The digital signature must be legible and contain the first and last name, credentials, and date.

d. Rubber stamp signatures are not permissible. This provision does not affect stamped signatures on claims, which remain permissible.

Documentation of Medical Services

Medical records are expected to contain all the elements required in order to file and substantiate a claim for the services as well as the appropriate level of care, i.e., evaluation and management service (see Policy Memo No. 2). Each diagnosis submitted on the claim must be supported by the documentation in the patient’s medical record.

The contracting provider agrees to submit claims only when appropriate documentation supporting said claims is present in the medical record(s) which shall be made available for audit and review at no charge.

Letters/checklists are not acceptable as documentation of medical necessity and do not replace what should be in the complete medical record. Abbreviations must be those that are generally accepted by your peers and clearly translated to be understandable to the reviewer.

2. BCBSKS has adopted the following standards for documentation of medical services.

Each patient’s health record shall meet these requirements:

a. Be legible in both readability and content.

b. Contain only those terms and abbreviations that are or should be comprehensible to similar providers/peers.

c. Contain patient-identifying information on each page to ensure pages are not lost or misfiled.

d. Indicate the dates any professional service was provided and date of each entry.

e. Contain pertinent information concerning the patient’s condition and justify the course of treatment. The record must document the medical necessity and appropriateness of each service.
f. Documentation of examination and treatment(s) performed or recommended (why it was done and for how long) and physical area(s) treated, vital signs obtained and tests (lab, x-ray, etc.) performed, and the results of each.

g. List start and stop times or total time for each CPT code/service performed on all timed codes per CPT nomenclature.

h. Document the initial diagnosis and the patient’s initial reason for seeking the provider’s care.

i. Document the patient’s current status and progress during the course of treatment provided.

j. Indicate the medications prescribed, dispensed, or administered, and the quantity and strength of each.

k. Include all patient records received from other health care providers if those records formed the basis for treatment decision by the provider.

l. Each entry shall be authenticated by the person making the entry (see Signature Requirements) unless the entire patient record is maintained in the provider’s own handwriting.
m. Each patient record shall include any writing intended to be a final record, but shall not require the maintenance of rough drafts, notes, other writings, or recordings once this information is converted to final form; the final form shall accurately reflect the care and services rendered to the patient.

why post payment audit happening in insurances


BCBSKS conducts periodic post-payment audits of patient records and adjudicated claims to verify congruence with BCBSKS medical and payment policies, including medical necessity and established standards of care. Post-payment audits can range from a basic encounter audit to determine if the level of care is accurately billed, to a complete audit which thoroughly examines all aspects of the medical record and medical practice. Post-payment audits are performed after the service(s) is billed to BCBSKS and payments have been received by the provider. BCBSKS cannot go back further than 15 months following the date of claim adjudication to initiate an audit. Due to additional time allowed for provider appeals, as outlined in this policy memo, refunds would be applicable after the provider appeals have been exhausted, regardless of the time frame involved. BCBSKS provides education through policy memos, medical policy, newsletters, workshops, direct correspondence, peer consultant medical opinion, and on-site visits.

If medical necessity is not supported by the medical record, BCBSKS will deny as not medically necessary. When BCBSKS requests medical records for an audit and no documentation is received within the 30-day time limit, BCBSKS will deny for no documentation. Services denied for failure to submit documentation are not eligible for provider appeal, and are a provider write-off.

Post-payment Audit Appeals:

A. First-Level Appeal

Services denied not medically necessary as a part of the post-pay audit process may be appealed in writing within 30 days of notification of the findings. Written notification of disagreement highlighting specific points for reconsideration should be provided with the appeal. The BCBSKS determination will be made within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.

B. Second-Level Appeal

A provider may request a second and final appeal in writing within 30 days of notification of the first-level appeal determination. The second and final appeal determination will be made by a physician or clinical peer within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.

When findings reveal issues, which are presently specified in BCBSKS policy memos, billing guidelines or newsletters relating to content of service, multiple surgery guidelines, and other billing and/or reimbursement guidelines, the terms of this appeal are not available


Providers are not reimbursed for professional services they provide to an immediate family member (“immediate family member” means the husband or wife, children, parents, brother, sister, or legal guardian of the person who received the service) or themselves as specified in the member contract.

There are several categories of services, procedures, equipment and/or pharmaceuticals that may be considered non-covered services when designated by the member’s contract. These denials are billable to the member. (

Medicaid Laboratory Billing Guide


MDHHS follows Medicare’s current OPPS coverage policies as closely as possible and appropriate. In those instances where program differences require coverage disparity, the differences will be reflected through the application of the MDHHS specific status indicator. Procedure codes associated with the identified services will appear on the MDHHS OPPS Wraparound Code List available on the MDHHS website. (Refer to the Directory Appendix for website information.)

MDHHS policy covers hospitals for medically necessary laboratory tests when:

* Performed in a laboratory certified by the Clinical Laboratory Improvement Amendments (CLIA);

* Needed to diagnose a specific condition, illness, or injury; and

* Ordered by physicians (MD or DO), podiatrists, dentists, nurse practitioners, or nurse-midwives.

MDHHS requires medical record documentation of medical necessity. An explanation of the laboratory testing method or the results of diagnostic tests, whether normal or abnormal, is not considered documentation of medical necessity. For approval of payment, the laboratory procedure(s) must be specific and appropriate to the beneficiary's documented condition and diagnosis.

Reimbursement to the inpatient hospital is through the DRG payment. Reimbursement for outpatient services is billed using the appropriate HCPCS code and includes the collection of the specimen(s), the analysis, and the lab test results. MDHHS performs pre- and/or postpayment reviews to monitor laboratory procedures for medical necessity and appropriate practitioner
orders. Outpatient hospitals are subject to corrective action, including the recovery of funds, for laboratory services not specifically ordered by a practitioner.

MDHHS does not cover:

* Screening or routine laboratory testing, except as specified for EPSDT Program or by Medicaid policy;

* "Profiles", "batteries" or "panels" of tests that include tests not necessary for the diagnosis or treatment of the beneficiary's specific condition; or

* Multiple laboratory tests performed as a part of the beneficiary evaluation if the history and physical examination do not suggest the need for the tests.

Services performed by an outpatient hospital laboratory or its employees may not be billed to, or by, the ordering practitioner.


The obstetric profile must be ordered by the attending practitioner and billed as an allinclusive panel of tests for required prenatal laboratory services. It must include the following:

* Blood count, complete (CBC), automated and automated differential WBC count, or Blood count, complete (CBC), automated and appropriate manual differential WBC count

* Hepatitis B surface antigen (HBaAg)

* Antibody, rubella

* Syphilis test, qualitative (e.g., VDRL, RPR, ART)

* Antibody screen, RBC, each serum technique

* Blood typing, ABO

* Blood typing, Rh(D)

Only AMA-approved organ- or disease-oriented panels may be billed. All tests within the panel must be medically necessary. Unless the complete panel is ordered and performed, bill as individual tests.

Testing for HIV is covered separately when determined to be medically necessary and ordered by the practitioner.

Only practitioners should order the serum or urine HCG qualitative method when the beneficiary requires preliminary pregnancy testing.

Nurse-midwives may order only the laboratory tests listed below. Hospitals are not reimbursed for any other tests ordered by a nurse-midwife.

* Acetone and diabetic acid (ketone bodies); qualitative; semi-quantitative

* Albumin; qualitative, semi-quantitative, quantitative (such as Esbach)

* Antibody titer Rh system; albumin, saline and/or AHG technique

* Blood count; RBC, WBC, Hemoglobin, Hematocrit, indices (MCV, MCH, MCHC)

* Blood typing; ABO, Rh(D), RBC antibody screening

* Culture, presumptive (screening), for Neisseria gonorrhea, Candida, Hemophilus, or beta hemolytic Streptococcus group A, etc.

* Culture, urine, definitive; with or without colony count

* Cytopathology, vaginal and/or cervical smears (e.g., Papanicolaou type) screening (cytopathological examination for malignancy, microbial flora, inflammatory features and hormonal evaluation)

* Glucose; qualitative, quantitative, timed specimen, tolerance

* Hemoglobin, electrophoretic separation; qualitative

* Hepatitis B test

* Human immunodeficiency virus detection

* Pregnancy test

* Prenatal laboratory services; routine (Obstetric panel)

* Quantitative sediment analysis and quantitative protein (Addis count); 12- or 24-hour specimen Reticulocyte count, manual

* Rubella test; titer

* Sickle cell slide test

* Skin test, tuberculosis, tine test

* Susceptibility (sensitivity) for aerobes by Kirby-Bauer procedure for specific pathogens, using 10-12 discs per pathogen; also for susceptibility (sensitivity) for anaerobes by generally accepted standard techniques using 5-12 discs per pathogen (specify number of pathogens)

* Syphilis testing, flocculation or precipitin (VDRL, RPR, etc.); qualitative

* Trepanema antibodies, fluorescent, absorbed (FTA-abs)

* Urinalysis, complete (physical appearance, pH, specific gravity, microscopic examination, qualitative chemistry with or without semi-quantitative confirmation)

* Wet mount, smear, tissue; direct microscopic examination


MDHHS reimburses for blood handling only when a beneficiary is referred to an outpatient hospital for the sole purpose of drawing, packaging and mailing a blood sample to MDHHS for HIV-1 viral load analysis and/or CD4/CD8 enumeration. The State provides specimen containers and mailin  kits for the analysis. (Requests for supplies and samples for analysis should be sent to the MDHHS Blood Lead Laboratory. Refer to the Directory Appendix for contact information.)


A complete blood count (CBC) with white blood cell (WBC) differential includes the RBC and WBC count, Hgb, Hct, MCH, MCHC, MCV, RBC morphology, platelet estimate, and WBC differential only. If automated instrumentation yields additional test parameters, the results are not reimbursable unless medically necessary and specifically ordered by a practitioner.


MDHHS coverage and reimbursement for gram fluorescent/acid fast is included in the reimbursement for microbiology when performed on the same DOS for the same beneficiary.


Pap smear screening by a technologist under the supervision of a pathologist is a covered service. If a suspect smear requires additional interpretation by a pathologist, this service is also covered. Only one Papanicolaou test within a 12-month period is covered for each beneficiary, unless medical necessity or history of abnormal findings requires additional studies.


For direct-billed laboratory services ordered by an approved CA, the referring provider NPI number must be appropriately reported on the appropriate paper or electronic claim format.


Calculate and report the Glomerular Filtration Rate (eGFR) for tests processed for beneficiaries in outpatient settings and for beneficiaries 18 years of age and older. The eGFR test results must report two values on the lab report for beneficiaries: one for American and one for non-African-American, or one value if race is available and able to be used in calculating the value.

Hospice Service billing - Complete overview

Hospice Billing INTRODUCTION

Hospice is a health care program designed to meet the needs of terminally ill individuals when the individual decides that the physical and emotional toll of curative treatment is no longer in their best interest. These individuals choose palliative care, which is not a cure, but ensures comfort, dignity and quality of life. Hospice is intended to address the full range of needs of the individual with a terminal illness, while also considering family needs. Care must be consistent with the individual’s values, regardless of the location where care is provided.

The primary objective of the Medicaid Hospice Program is to ensure that essential medical/health services are available to those who would not otherwise have the financial resources to purchase them. Medicaid policies are designed to achieve this objective with fiscal responsibility. Hospice providers must verify eligibility before providing services. Hospice beneficiaries are identified in the eligibility response with the Benefit Plan ID of Hospice. (Refer to the Beneficiary Eligibility chapter for additional information.)


Hospice providers are bound to all rules, regulations, and policies specified in this chapter for program participation/enrollment of Medicaid beneficiaries. Hospice providers must also comply with the Medicare Conditions of Participation (42 CFR § 418) which generally apply to non-Medicare beneficiaries as well as to Medicare beneficiaries.

Additional information regarding federal Hospice requirements and guidelines is contained in the Centers for Medicare & Medicaid Services (CMS) State Operations Manual 2083.

Michigan Department of Health and Human Services (MDHHS) requires Hospice agencies to be licensed in Michigan by the state-licensing agency, certified by Medicare, and enrolled in Medicaid. (Refer to the General Information for Providers Chapter of this manual for additional information.)

Hospice providers cannot engage in any of the following marketing-related practices:

* Provide cash, gift incentives, or rebates to prospective covered persons;

* Claim superior medical care or provider skills; or

* Make untruthful statements regarding the merits of the hospice.

The use of marketing practices that mislead, confuse, or defraud either the beneficiary or MDHHS is considered grounds for terminating the hospice from participation in Medicaid. Such actions may also result in investigation leading to possible prosecution under applicable State and Federal statutes.



A terminally ill Medicaid beneficiary who lives in a hospice service area and whose life expectancy is six months or less (if the illness runs its normal course), as determined by a licensed physician and the Hospice Medical Director, has the option to enroll in a hospice program. A representative, such as a spouse, parent, legal guardian, or other authorized adult, may act on behalf of the beneficiary.

Medicaid does not cover Hospice services if the following conditions exist:

* The individual is not eligible for the Medicaid benefit.

* The beneficiary does not meet the hospice’s enrollment criteria.

* If the beneficiary is currently enrolled in a Medicaid Health Plan (MHP), the hospice services must be arranged and reimbursed by the MHP.

All Hospice enrollment activities must be conducted according to MDHHS policies and in such a manner as to maximize the beneficiary’s ability to make a choice between enrollment in hospice or maintaining current active treatment with Medicaid coverage. Such activities must assure that the beneficiary fully understands how to use hospice services and that all care must be received from or through the hospice (except those services not related to the terminal illness or services provided by his attending physician).

It is imperative that the Hospice provider read the Conditions of Enrollment on the Hospice Membership Notice form (DCH-1074) to the beneficiary and answer any questions raised by the beneficiary. (Refer to the Forms Appendix for an example of the DCH-1074 and instructions for its completion.)


Hospice providers are responsible for enrolling beneficiaries for hospice services. A DCH-1074 must be completed, including the signature of the beneficiary or his legally appointed representative. Fax the completed form to the MDHHS Enrollment Services Section. (Providers are not required to submit the form by US mail.) A copy of the form must be given to the beneficiary, and the original filed in the beneficiary’s record. Do not submit the form if the beneficiary is enrolled in the Adult Home and Community Based Waiver (MI Choice).

A copy of the following information must be retained in the beneficiary’s record:

* Hospice Membership Notice form (DCH-1074).

* Effective date of enrollment. (If the date entered on the DCH-1074 is changed, the hospice must contact the beneficiary to notify him of the new effective date.)

* Hospice enrollment identification card (if the hospice chooses to issue one to their beneficiaries).


Hospice providers must provide Medicaid beneficiaries with the following materials and written information within ten days of the effective date of enrollment in hospice:

* Conditions of enrollment, including:

* Scope, content, and duration of coverage;

* Enrollee grievance procedure; and

* Beneficiary responsibility for reporting coverage by any other insurance.

* Procedures for obtaining health care, including:

* Address, telephone number, and service hours of the health care providers;

* Emergency medical care (other than for the treatment of the terminal illness); and

* Health care provision outside of the hospice.



A beneficiary eligible for hospice may receive hospice services in their home. If the beneficiary is eligible for hospice services but does not have family or friends to provide the necessary home care, the beneficiary may live in a residential setting that may include an Adult Foster Care (AFC) facility, boarding home, Home for the Aged (HFA), or assisted living facility. The setting must be appropriate for the type of care required by the beneficiary. Medicaid does not pay room and board in these settings.

Beneficiaries may receive hospice services in these settings. The hospice is responsible for developing and implementing a coordinated plan of care to avoid duplication ofservices. These care settings are available for Medicare, Medicaid, and dually eligible beneficiaries.


When a dually enrolled Medicare/Medicaid beneficiary enters a nursing facility (NF), the beneficiary can elect the Medicare hospice benefit if that NF has hospice services available. In this case, the beneficiary revokes the 100 days of Medicare reimbursement for skilled NF care.

Revocation of the 100-day NF skilled care is a beneficiary’s decision and should not be influenced by the NF’s funding source for the bed.

The DCH-1074 is used as the benefit election form for Medicaid eligible beneficiaries.

This does not mean that the beneficiary has revoked the Medicare benefit for services not related to their terminal illness. The beneficiary remains eligible for Medicare, but has elected to use only the hospice portion of the Medicare benefit.

If the NF contracts to make hospice services available, the hospice must provide DCH-1074 forms to Medicaid, Medicare and dually eligible beneficiaries. The facility must provide room and board for the beneficiary, and the hospice must provide its normal services.

The Pre-Admission Screening/Annual Resident Review (PASARR) form (DCH-3877) must be completed for a hospice patient entering a NF unless the hospice beneficiary is entering for a five-day respite period. The DCH-3877 is not required for the respite
period. The DCH-3877 is to identify ind ividuals who may have a mental illness or intellectual disability. If the patient is on antipsychotic, antianxiety, or antidepressant medications for purposes of pain control/symptom relief for end of life, it should be noted on the DCH-3877. This allows the Community Mental Health Services Program (CMHSP) worker to better evaluate the need for further (Level II) screening. If the patient is on any of the above mentioned psychotropic medications for a related mental illness, the CMHSP will determine the need for a Level II screening.

Medicaid will reimburse the hospice for room and board for a hospice beneficiary who resides in a NF (including a beneficiary for whom a complex care authorization has been approved) or in a Ventilator Dependent Care Unit (VDCU). The hospice then reimburses the NF. The Medicaid reimbursement to the hospice for NF room and board is equal to 95% of the total Medicaid NF rate. For Class I, III, and V facilities, reimbursement also includes 100% of the Quality Assurance Supplement (QAS) amount due the NF through the Quality Assurance Assessment Program (QAAP). QAS funds are not included in the reimbursement for Hospital Swing Beds as they are not eligible for that program.

Per Medicare guidelines, the term "room and board" in a NF includes the performance of personal care services that a family caregiver would provide if the individual were at home. This includes assistance in the activities of daily living such as bathing, grooming, toileting, dressing, meal service, socializing, companionship, hobbies, administration of medication, maintaining the cleanliness of the beneficiary’s bed and room, and supervising/assisting in the use of durable medical equipment (DME) and prescribed therapies (e.g., range of motion, speech and language exercises). The NF may not include hospice staff to meet its staffing requirements.

Hospice covered beneficiaries residing in the NF must not experience any lack of NF services or personal care due to their status as a hospice beneficiary. NFs must offer the same drugs, services, medical supplies and DME to all residents who have  lected the hospice benefit in the same manner that services are provided to other residents in the facility who have not elected hospice care. If a service is normally furnished as part of the facility’s per diem, the service must also be provided to hospice beneficiaries. If services are provided for needs associated with a non-terminal illness and are normally furnished and billed by another provider, that practice would continue.


Medicaid hospice reimbursement includes payment for any hospitalizations related to the terminal illness. The hospice must contract with, and reimburse, a hospital for medically necessary inpatient services related to the beneficiary’s terminal illness. Medicaid does not reimburse the hospital separately unless the hospitalization is not related to the terminal illness.


Based on hospice eligibility criteria, the duration of hospice services is generally six months or less. There is no minimum period of hospice enrollment. A change in the beneficiary’s prognosis could eliminate the need for hospice care. A beneficiary may cancel his enrollment in the hospice at any time and without cause. Beneficiaries who become ineligible for Medicaid while enrolled in a hospice also become ineligible for Medicaid reimbursement for hospice services.


A beneficiary may disenroll or be discharged from hospice as noted below. A DCH-1074 indicating the reason for the disenrollment or discharge must be signed and dated by the beneficiary and/or authorized representative as proof of notification (unless the beneficiary has expired). The hospice must submit a copy of the disenrollment notice to the MDHHS Enrollment Services Section. (Refer to the Directory Appendix for contact information.)


When a hospice-enrolled beneficiary dies, the hospice must complete the DCH-1074 indicating the date the beneficiary expired and submit it to MDHHS.


A beneficiary may choose to disenroll from, or revoke their election of, hospice care at any time during an election period. The hospice must obtain written documentation, signed and dated by the beneficiary or their representative, stating they are revoking the hospice benefit for the remainder of that election period. The disenrollment or revocation is effective with the date of the beneficiary’s/representative’s signature. The hospice must give a copy of the disenrollment notice to the beneficiary when he signs it and retain another copy in the beneficiary’s record.


A beneficiary should not revoke, disenroll, or be discharged from hospice for the purpose of admission to the hospital for care related to the hospice diagnosis. Medicaid does not reimburse the hospital separately unless the hospitalization is not related to the terminal illness. When this is the case, the hospice may continue to provide care to the beneficiary under the routine hospice care benefit.


An enrolled beneficiary may have a change in condition and no longer qualify for hospice services. If the beneficiary is discharged for this reason, the hospice must send a copy of the DCH-1074 (indicating the disenrollment) to the beneficiary along with a letter explaining the reason and effective date for the disenrollment.


The hospice is responsible for verifying the beneficiary’s continued Medicaid eligibility once he is enrolled. Medicaid does not reimburse hospice services rendered to a Medicaid ineligible beneficiary.


At the time of enrollment, beneficiaries must be told to notify the hospice and their local MDHHS worker if their place of residence changes. If the new residence is located in the hospice’s normal service area, or if the hospice agrees to continue to provide services to the beneficiary, the move creates no changes except an address change. However, if the move is too far for the hospice to continue services for the beneficiary, the hospice must arrange a transfer of care for the beneficiary to another Medicaid enrolled hospice. The two hospices must work together to assure that no lapse occurs in services to the

The effective date of disenrollment for a beneficiary who has moved is the day that the beneficiary moves. It is preferable that the DCH-1074 indicating the disenrollment from the first hospice, and the DCH-1074 indicating enrollment for the second hospice be sent to MDHHS together. If the notices are sent separately, each hospice must place an explanation in the Remarks box on the DCH-1074 indicating the reason for the transition to the new hospice.


The hospice may discharge a beneficiary if the beneficiary violates any of the conditions of membership in the hospice. The decision to discharge a beneficiary and the effective date of the discharge aredetermined on an individual basis by the hospice Medical Director.

The hospice may request disenrollment of a beneficiary for any of the following reasons:

* Fraud;

* Abuse (including repeated instances of willfully and knowingly obtaining health care services for the terminal illness from non-hospice providers); or

* Misconduct (including violence that interferes with or interrupts the provider’s proper delivery of health care to the patient or other patients)



The duration of hospice coverage is measured in election periods, also known as benefit periods. A beneficiary may elect to receive hospice care during one or more of the following election periods:

* An initial 90-day period;

* A subsequent 90-day period; or

* An unlimited number of subsequent 60-day periods.


A hospice must obtain written certification of the terminal illness for each election period before a claim for services is submitted. If the hospice is unable to obtain a written certification within three days of initiation of hospice care, a verbal certification must be obtained, documented, and signed by the person receiving the certification. Statements covering a beneficiary’s initial certification must be obtained from the hospice medical director or the physician member of the Interdisciplinary Group (IDG), and the beneficiary’s attending physician if the beneficiary has an attending physician. The hospice medical director or the physician member of the IDG certifies the terminal illness for all subsequent election

Each written certification must include:

* A statement that the beneficiary’s life expectancy is six months or less if the terminal illness runs its normal course;

* Specific clinical findings and other documentation as needed to support the life expectancy of six months or less;

* A brief narrative summary;

* An explanation why the clinical findings of the face-to-face encounter support a life expectancy of six months or less (beginning with the third benefit period and thereafter); and

* Physician signature(s), date signed, and specific election period dates covered by the certification or recertification.

Documentation of all written/verbal certifications must be prepared no more than 15 calendar days prior to the effective date of election and must be kept in the beneficiary’s medical record.


Each hospice certification and recertification must be accompanied by a brief narrative describing the clinical findings supporting the beneficiary’s life expectancy of six months or less. Each narrative must reflect the clinical circumstances and should not contain checkboxes or non-specific, standard language.


A hospice physician, hospice-employed nurse practitioner (NP), or hospice-employed physician assistant  (PA) must have a face-to-face encounter with every hospice beneficiary prior to the 180th day of recertification of the beneficiary’s terminal illness for the purpose of determining continued eligibility. The 180th day recertification is defined as the recertification that occurs at the start of the third benefit (election) period or the benefit period following the second 90-day benefit period. Additionally, a face-toface must be conducted at each subsequent recertification (every 60 days thereafter) for as long as the beneficiary is in hospice. Face-to-face encounters must occur no more than 30 calendar days prior to the  start of the third benefit period and no more than 30 calendar days prior to each subsequent benefit period thereafter.

The hospice physician, NP, or PA must attest in writing to the face-to-face encounter with the beneficiary and include the date of the visit. A NP or PA is allowed to perform and attest to the face-to-faceencounter; however, the hospice physician must certify and recertify the terminal illness.

Failure to meet the face-to-face encounter requirements results in a failure by the hospice to meet the recertification of the terminal illness requirement. This results in the beneficiary no longer being eligible for the hospice benefit. If this should happen, the hospice must complete a Hospice Membership Notice (form DCH-1074), with the last date of the benefit period as the effective disenrollment date. A comment in the Remarks Section of the form is required to explain the reason for the disenrollment.

There may be an occasional case when a hospice admits a beneficiary who received services from another hospice provider, and the beneficiary chose to revoke or was discharged from that provider. When this occurs, the admitting hospice may begin their care with the beneficiary’s first benefit period unless the beneficiary is a direct transfer from the other hospice. When this is the case, the beneficiary’s benefit period remains the same, and the transferring hospice should provide the receiving hospice with all required documentation. A hospice resuming care for a beneficiary formerly served by their hospice must restart care in the next or subsequent benefit period.



The hospice must provide all or substantially all of the core services applicable for the terminal illness in the beneficiary’s home. (Home may include the beneficiary’s private dwelling, apartment, boarding home, assisted living facility, AFC facility, HFA, NF or hospice-owned NF.)

These core services are:

* Physician care

* Nursing care

* Social work

* Counseling

* Bereavement

* Spiritual

* Dietary


Other services that may be necessary due to the terminal illness and must be available but are not considered core services are:

* Drugs*/Biologicals

* Home Health Aide services

* Homemaker services

* Medical Supplies/Durable Medical Equipment (DME)

* Occupational Therapy

* Physical Therapy

* Short-Term Inpatient care

* Speech Therapy

These other services may be provided by contractual agreement or provided by the hospice directly and are not reimbursed separately.



If a beneficiary is dually enrolled in Medicare and Medicaid, he must receive hospice coverage under the Medicare benefit. (Medicaid is the payer of last resort.) If the beneficiary resides in a NF, Medicare may pay hospice services, with NF room and board paid for by Medicaid. When a beneficiary is receiving services through the Medicare hospice benefit, Medicaid does not pay for curative or duplicative services.

The hospice provider must complete the DCH-1074 whenever Medicaid is billed (i.e., coinsurance, deductibles, and room and board in the NF or hospice-owned NF).

If the hospice benefit is revoked under Medicare, the beneficiary cannot use the Medicaid hospice benefit as a replacement. Hospices should carefully explain this situation to the dually eligible beneficiary, especially during the fourth Medicare benefit period.* However, if the dually eligible beneficiary is no longer appropriate for hospice care and is disenrolled as a hospice beneficiary, that beneficiary is able to re-enroll with the hospice for the Medicaid benefit period if he becomes eligible for hospice again.


Hospice services are included in the Medicaid Health Plan (MHP) covered services package for Medicaid enrollees. If the terminally ill enrollee requests and meets the criteria for hospice services, the MHP must cover the requested hospice services. If the terminally ill enrollee does not request hospice services, theMHP may provide its own array of services for the terminally ill. If the beneficiary is enrolled in a MHP (eligibility response indicates the Benefit Plan ID of MA-MC or MA-HMP-MC), the hospice must contact the MHP immediately to receive prior authorization (PA) from the MHP before furnishing services. The MHP may require its enrollees to receive hospice services through a contracted hospice with which they have made arrangements. MHPs are responsible for the hospice care arrangement and payment if the eligibility response indicates a Benefit Plan ID of MA-MC or MA-HMP-MC for the beneficiary.

If a fee-for-service (FFS) Medicaid beneficiary is automatically enrolled in a MHP while receiving hospice care, the beneficiary or his representative should contact the MDHHS Hospice Enrollment Coordinator if he wishes to continue receiving services from his current hospice provider. (Refer to the Directory Appendix for contact information.) The hospice enrollment coordinator initiates the process of disenrollment from the MHP. It is not the intent of MDHHS to disrupt a hospice beneficiary’s care through automatic enrollment in a MHP. If the beneficiary subsequently disenrolls or is discharged from hospice care, the beneficiary may be offered the opportunity to join a MHP. If the MHP enrollee requires hospice services in a NF or hospice-owned NF, the MHP pays a negotiated rate for room and board in addition to the payment for the hospice services. The hospice must contact the MHP prior to enrolling the beneficiary to request authorization by the MHP.


MDHHS employs the following standards when reimbursing for hospice care:

MDHHS uses the Medicaid hospice payment base rates established and provided by CMS and applies the appropriate local wage adjustors provided by CMS for the four categories of hospice care in each Core Based Statistical Area (CBSA). Medicaid Fee for Service hospice providers who have not submitted required quality data to the Centers for Medicare & Medicaid Services (CMS) in compliance with the Hospice Quality Reporting Program (HQRP) will receive reduced reimbursement. Medicaid publishes and implements rate updates each fiscal year or when directed by CMS. (Refer to the MDHHS Hospice Reimbursement Rates on the MDHHS website.)


When a Medicaid beneficiary is receiving hospice services under Medicare, the hospice may bill Medicaid for the coinsurance, as well as room and board, if the beneficiary resides in a NF or hospice-owned NF. Coinsurance and/or room and board cannot be billed to a Medicaid beneficiary, his family, or his representative.


Hospice services are reimbursable for day of discharge if services were rendered, regardless of the setting in which the services were provided. This includes the t ransfer of the beneficiary from one hospice provider to another as long as services were provided by both agencies. (This will be randomly verified by post payment audit and as indicated.) If the beneficiary has hospice as of 12:01 am, the hospice is responsible for the payment of services provided to the beneficiary until midnight. The hospice will continue, for payment purposes, as the primary provider for the full day of discharge.

Room and board for a hospice/nursing facility (NF) resident is reimbursable on the day of discharge if the discharge is due to resident death or the resident is discharged from hospice but remains in the NF. Room and board reimbursement for the day of discharge from the NF for any other reason is not covered.


Reimbursement for administrative duties performed by the Medical Director is included in normal hospice rates. Direct patient care provided by the Medical Director, hospiceemployed physician or consulting physician may be billed by the hospice and is separately reimbursable based on the lesser of Medicaid’s maximum allowable amount for the service or the charge. Claims must reflect the Healthcare Common Procedure Coding System (HCPCS) procedure codes for the physician’s direct patient care.


If the Medicaid beneficiary residing in a NF has a patient-pay amount (PPA), the hospice must collect that amount each month and apply it toward the beneficiary’s Medicaid covered services, and non-covered services as allowed by Medicaid. While the hospice is responsible for collecting the PPA, this duty may be delegated to the NF (via contract with the hospice) as long as the amount is applied to the room and board bill. The PPA must be exhausted each month (even if services do not span the entire month) before any Medicaid payment can be made. Whenever the hospice collects a PPA, a receipt must be given to the beneficiary (or family).

The provider must bill Medicaid for services rendered even if the PPA exceeds the Medicaid reimbursement rate resulting in a zero dollar payment. The Hospice Claim Completion Section of the Billing & Reimbursement for Institutional Providers Chapter
contains examples of the application of the PPA.

CHAMPS handles the PPA in the following manner: When a beneficiary has a monthly PPA and a level of care (LOC) for nursing facility (02) and hospice (16) on file, the PPA will be deducted from the first claim received in CHAMPS. This will occur regardless of whether the PPA is located on the eligibility segment for LOC 02 or LOC 16, and the higher PPA amount will be deducted. If the PPA is greater than the amount of the first submitted claim, the difference will be applied to subsequent claims until the total PPA for that month is met. The PPA must be exhausted each month before any Medicaid payment will be made. The nursing facility and hospice must bill in sequence according to the level of care the beneficiary was at on the first of the month. This will prevent the PPA from being deducted from the wrong claim.


For necessary medical or remedial care recognized under State law but not covered by Medicaid, the Medicare Catastrophic Coverage Act of 1988, Public Law 100-360, allows NF beneficiaries to access their patient-pay amount to pay for these services as allowed by Medicaid. If Medicare covers the beneficiary’s need for medical services, then Medicaid continues to cover the Medicare deductible and coinsurance in the event it does not exceed the Medicaid fee screen.


The hospice must verify eligibility before providing hospice services to the beneficiary in a home setting. (Refer to the Beneficiary Eligibility chapter for additional information.) If the eligibility response indicates a Benefit Plan ID of Spend-down, the hospice should askthe beneficiary or their responsible person for a copy of the MDHHS letter sent the first of each month which indicates the dollar amount the beneficiary must spend before becoming Medicaid-eligible for services. Medicaid may not be billed until the Medicaid deductible obligation is met and the eligibility response indicates a Benefit Plan ID of MA or MA-HMP.


When Medicaid reimburses the hospice for room and board in a NF, the beneficiary must be placed in a bed certified by Medicaid (i.e., a Medicare/Medicaid certified bed or one certified Medicaid-only). If the beneficiary is not placed in a bed certified for Medicaid, MDHHS does not pay for any services. MDHHS pays the hospice 95 percent of the individual or specific facility’s Medicaid rate for room and board plus 100 percent of the nursing facility’s Quality Assurance Supplement (QAS) rate. Hospice reimbursement to  the NF for room and board must be outlined in the contract established between the hospice and the NF.

* Holding a Bed (Hospital Leave and Therapeutic Leave). For NF beneficiaries on hospice, Medicaid reimburses the hospice for holding a NF bed as indicated below.  Hospice reimbursement to the NF for bed holds must be outlined in the contract between the NF and the hospice.

Family members/responsible parties for the hospice/NF beneficiary must be informed of the bed hold and readmission policy of the NF. If the beneficiary refuses to have a family member/responsible party notified, this must be documented in the beneficiary’s medical record.

* Hospital Leave Days. For Hospital Leave Days, Medicaid will pay to hold a beneficiary’s bed only when the facility’s total available bed occupancy is at 98 percent or more on the day the beneficiary leaves the facility. Facilities at 97.5 percent occupancy may round up to 98 percent. Medicaid reimburses during a beneficiary's temporary absence (up to 10 days) from the NF for admission to the hospital for emergency medical treatment as documented by the attending physician in the beneficiary’s medical record.

The facility must hold the bed, and the hospice may bill Medicaid, if the attending physician documents a reasonable expectation at the point of admission to the hospital that the beneficiary will return to the NF by the end of the 10th day.

The beneficiary must return to the NF within 10 days for the hospice to bill for hospital leave days. If the beneficiary is in the hospital for more than 10 days, the NF is released from its obligation to hold the bed and the hospice cannot bill Medicaid for any leave days. Reimbursement to the hospice is at 100 percent of the class wide NF hospital leave day rate. This rate, determined annually by MDHHS, is available on the MDHHS website. (Refer to the Directory Appendix for website information.)

If the beneficiary is expected to be in the hospital for 10 days or fewer, and dies while in the hospital, the hospice may bill Medicaid for the hospital leave days up to the day before the beneficiary died.

If the beneficiary returns to the NF under Medicare coverage and still elects hospice care, the hospice may bill Medicaid for the hospital leave days if the emergency hospitalization was for no more than 10 consecutive days.

Patient-pay amounts and billing methods are not affected by this hospital leave day policy. The hospice/NF should continue to collect any patient-pay amount, typically on the first day of the month, and indicate the amount collected on the Medicaid claim.

CHAMPS automatically deducts the patient-pay amount and reimburses the provider for the balance. If the hospice bills Medicaid for hospital leave days that occur at the beginning of the month, then the hospice should collect the patient-pay amount as usual.

The hospice should charge the amount against the patient-pay that Medicaid pays for that day. For example, if a beneficiary has a patient-pay of $200 and is in the hospital for an emergency condition for the first five days of the month (the stay totals no more than 10 consecutive days), the hospice should collect the patient-pay amount from the beneficiary and then submit a Medicaid claim. Medicaid reimburses the hospice for the hospital leave day per diem rate, minus the patient-pay amount. The hospice reimbursement, based on 2003 rates, would be $132.80 [($66.56 x 5) - $200].

* Therapeutic Leave Days. If the beneficiary has a temporary absence from the NF for therapeutic reasons approved by the attending physician, the hospice may be reimbursed by Medicaid to hold the bed open for up to a total of 18 days during a 365-day period.

Therapeutic leave is for nonmedical reasons such as overnight stays with friends/relatives, Make-a-Wish Foundation trips, etc. The beneficiary’s POC must provide for such absences. There is no limit to the number of therapeutic leave days that may be reimbursed at one time as long as the total does not exceed 18 days in a 365-day period. If a beneficiary does not return from a therapeutic leave, the beneficiary must be discharged on the date he left the facility. The date of admission and the date of discharge may not be billed as therapeutic leave days.

Reimbursement is at 95 percent of the individual or specific NF’s daily per diem rate, just as the customary room and board rate is reimbursed.

* Hospice Revocation or Decertification. If a Medicaid hospice beneficiary who resides in a NF revokes his hospice services or is deemed no longer certifiable for the Medicaid hospice benefit, the hospice may bill for services on the day of revocation/ decertification, as well as the hospice/NF room and board, as long as the beneficiary is in the facility at the midnight census.

* Ventilator Dependent Care Unit (VDCU) or Complex Care Case. Refer to the Place of Service subsection of this chapter for information regarding payment of room and board for these hospice beneficiaries.


Medicaid does not reimburse for room and board in these settings. Reimbursement is  made directly to the facility provider in the normal manner (i.e., Supplemental Security Income, Personal Care/Supplemental Payment). This payment is made in full. The AFC or HFA cannot seek additional restitution from the beneficiary or the hospice provider.


Medicaid does not reimburse for room and board in these settings.


Medicaid does not reimburse for room and board in these settings.


Medicaid does not apply an aggregate dollar capitation. (The Medicare program establishes the maximum total dollar amount per year that Medicare pays for hospice services. Medicaid does not apply this policy to beneficiaries receiving hospice care.)
Medicaid applies the same number of inpatient respite days as Medicare (i.e., no more than five consecutive days are allowed). If more than five consecutive days are billed, the number is reduced to five days, and the excess days must be billed as routine care by the hospice.

Reimbursement for routine, non-emergent transportation is included in the per diem (room and board amount) negotiated between the hospice and the NF.

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