Hospices

10.2.1.7 - Hospices (Rev.: 12796; Issued: 08-15-24; Effective: 09-16-24; Implementation: 09-16-24) A. General Background Information A hospice is a public agency or private organization or subdivision of either of these that is primarily engaged in providing a comprehensive set of services such as the assessment and management of pain. Typically, the need for services is identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care. B. Processing Instructions for Hospice Initial Form CMS-855A Applications 1. Receipt of Application Upon receipt of a hospice initial Form CMS-855A application, the contractor shall undertake the following (in whichever order the contractor prefers unless directed otherwise in this chapter): (A) Perform all data validations otherwise required per this chapter. (B) Ensure that the application(s) is complete consistent with the instructions in this chapter. (C) Ensure that the hospice has submitted all documentation otherwise required per this chapter. For hospice initial enrollment, this also includes the following: • Form CMS-1561 (Health Insurance Benefit Agreement, also known as a “provider agreement”) • Evidence of successful electronic submission of the Form HHS-690 through the Office of Civil Rights (OCR) portal, as applicable. (Evidence should be either written or electronic documentation.) (See https://www.hhs.gov/sites/default/files/forms/hhs-690.pdf for more information.) (The hospice must complete, sign, date, and include the Form CMS-1561, though the hospice need not complete those sections of the form reserved for CMS. For organizational hospices, an authorized official (as defined in § 424.502) must sign the form; for sole proprietorships, the sole proprietor must sign.) Notwithstanding the foregoing, if the Form CMS-1561 or the Form HHS-690 evidence is missing, unsigned, undated, or otherwise incomplete, the contractor need not develop for the form(s) or the information thereon; the contractor shall instead notify the state in its recommendation letter which document(s) was/were missing or otherwise incomplete. For all other missing or incomplete required documentation, the contractor shall follow the normal development instructions in this chapter. 2. Conclusion of Initial Contractor Review (Nothing in this section 10.2.1.7(B) prohibits the contractor from returning or rejecting the hospice application if otherwise permitted to do so per this chapter. When returning or rejecting the application, the contractor shall follow this chapter’s procedures for doing so.) (A) Approval Recommendation If, consistent with the instructions in section 10.2.1.7(B)(2) and this chapter, the contractor believes an approval recommendation is warranted, the contractor shall send the recommendation to the state pursuant to existing practice and this chapter’s instructions. The contractor need not copy the SOG Location or PEOG on the recommendation. Unless CMS directs otherwise, the contractor shall also send to the provider the notification letter in section 10.7.5.1(E) of this chapter. The state will: (1) review the recommendation package for completeness; (2) review the contractor’s recommendation for approval; (3) perform any state-specific functions; and (4) contact the contractor with any questions. The contractor shall respond to any state inquiry in Item (4) within 5 business days. If the inquiry involves the need for the contractor to obtain additional data, documentation, or clarification from the hospice, however, the timeframe is 15 business days; if the provider fails to respond to the contractor within this timeframe, it shall notify the state thereof. The contractor may always contact its PEOG BFL should it need the latter’s assistance with a particular state inquiry. (B) Denial If the contractor determines that a denial is warranted, it shall follow the denial procedures outlined in this chapter. This includes: (1) using the appropriate denial letter format in section 10.7.5.1 of this chapter; and (2) if required under section 10.6.6 (or another CMS directive) of this chapter, referring the matter to PEOG for review prior to denying the application. 3. Completion of State Review The state will notify the contractor once it has completed its review. There are two potential outcomes: (A) Approval Not Recommended If the state does not recommend approval, it will notify the contractor thereof. (The contractor may accept any notification that is in writing (e-mail is fine).) The site visit described in subsection (D)(1) below need not be performed. No later than 5 business days after receiving this notification, the contractor shall commence the actions described in section 10.2.1.7(B)(2)(B) above. (B) Approval Recommended If the state recommends approval, it will typically do so via a Form CMS-1539; however, the contractor may accept any documentation from the state signifying that the latter recommends approval. (Note that the contractor will not receive a formal tie-in notice.) No later than 5 business days after receipt of the recommendation from the state, the contractor shall order the site visit described in subsection (D)(1) below. If the hospice fails the site visit, the contractor shall follow the denial procedures addressed in subsection (B)(2)(B) above. If the hospice passes the site visit, the contractor (within 3 business days of completing its review of the results) shall send an e-mail to MedicareProviderEnrollment@cms.hhs.gov with the following information and documents: • The Form CMS-855 application (or PECOS Application Data Report) and all application attachments. • A copy of the Form CMS-1539 from the state or similar documentation received from the accrediting organization. • A copy of the provider-signed Form CMS-1561. • A copy of the draft approval letter, with the effective date shown on the Form CMS-1539 (or similar documentation) included in the draft letter. (See section 10.7.5.1 for the model approval letter.) PEOG will countersign the provider agreement. Based on the information received from the contractor, PEOG will also (1) assign an effective date, (2) assign a CCN, (3) enter the relevant data into the applicable national database, and (4) approve (with possible edits) the approval letter. Within 5 business days of receiving from PEOG the signed provider agreement, effective date, and CCN, the contractor shall: (1) send the approval letter and a copy of the CMS- countersigned provider agreement to the hospice; (2) send a copy of both the approval letter and the provider agreement to the state and/or accrediting organization (as applicable)); and (3) switch the PECOS record from “approval recommended” to “approved” consistent with existing instructions. C. Multiple Practice Locations Hospices are not precluded from having multiple practice locations if permitted by the state. If the state disapproves an additional practice location, the location must seek Medicare approval as a separate hospice with its own enrollment and provider agreement. (See Pub. 100-07, chapter 2, section 2088 for the policies regarding multiple hospice locations.) If the hospice submits a change of information application to add or relocate a practice location, the contractor shall process the application consistent with section 10.6.1.2 of this chapter. The contractor should be aware, however, that the state may not approve the location addition/change. D. Site Visits 1. Initial application - The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter. The NSVC will perform the site visit. The contractor shall not convey Medicare billing privileges to the provider prior to the completion of the NSVC’s site visit and the contractor’s review of the results. 2. Revalidation – If a hospice submits a revalidation application, the contractor shall order a site visit through PECOS. This is to ensure that the provider is still in compliance with CMS’s enrollment requirements. The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter. The NSVC will perform the site visit. The contractor shall not make a final decision regarding the revalidation application prior to the completion of the NSVC’s site visit and the contractor’s review of the results. 3. New/changed location - If a hospice is (1) adding a new location or (2) changing the physical location of an existing location, the contractor shall order a site visit of the new/changed location through PECOS no later than 5 business days after the contractor receives the approval recommendation from the state but before the contractor sends to PEOG the applicable e-mail described in section 10.6.1.2(A)(3) of this chapter. (See the latter section for more information.) This is to ensure that the new/changed location complies with CMS’s enrollment requirements. The scope of the site visit will be consistent with sections 10.6.20(A) and 10.6.20(B) of this chapter. The NSVC will perform the site visit. The contractor shall not make a final decision regarding the change of information application prior to the completion of the NSVC’s site visit and the contractor’s review of the results. E. Out-of-State Hospice Operations Pub. 100-07, chapter 2, section 2085 states that when a hospice furnishes services across state lines: • It must be certified by the state in which its CCN is based. • The involved states must have a written reciprocal agreement permitting the hospice to provide services in this manner. In those states that have a reciprocal agreement, hospices need not be separately enrolled in each state; consequently, they would not have to obtain a separate Medicare provider agreement/number in each state. Hospices residing in a state that does not have a written reciprocal survey agreement with a contiguous state are precluded from providing services across state lines; the hospice must establish a separate location in the state in which it wishes to provide services. See section 10.3.1.1.4(D) of this chapter for additional information regarding the enrollment of out-of-state hospice locations. In the event of any inconsistency between the instructions in sections 10.3.1.1.4(D) and 10.2.1.7(E), the latter takes precedence. F. Recommendation Before New Hospice Location Established If a hospice is adding a new location or changing the site of an existing one, the contractor can make a recommendation for approval to the state prior to the establishment of the new/changed location (notwithstanding any other instruction in this chapter to the contrary) in accordance with Pub. 100-07, chapter 2, section 2088. If the contractor opts to make such a recommendation prior to the location’s establishment or movement, it shall note in its recommendation letter that the location is not yet established or has not yet moved. G. Practice Locations and Mergers/Acquisitions Notwithstanding section 10.2.1.7(C) above, hospices cannot merge and allow the other locations to become multiple locations of the hospice because this hinders CMS and/or the state in evaluating compliance with 42 CFR § 418.100(f). The hospice will need to file a CHOW or a voluntary termination of the non-surviving site; the surviving hospice can then submit a Form CMS-855A to add a new multiple location in accordance with Pub. 100-07, chapter 2, section 2088. H. Additional Information: For more information on hospices, refer to: • Sections 1861(u) and 1861(dd) of the Social Security Act • 42 CFR Part 418 • Pub. 100-07, chapter 2, sections 2080 – 2089 • Pub. 100-04, chapter 11 • Pub. 100-02, chapter 9