Dual Eligibles

Dual Eligibles A. The hospice benefit must be used simultaneously under Medicare and Medicaid with Medicare providing primary coverage for dual eligible beneficiaries. B. The Division of Medicaid requires the hospice provider to submit the Notice of Hospice Election or Discharge for Dual Eligible Beneficiaries (Form DOM 1166C) to the Division of Medicaid’s Utilization Management/Quality Improvement Organization (UM/QIO) within five (5) calendar days of the beneficiary’s hospice election or discharge date. 1. If the hospice provider fails to submit Form DOM 1166C to the UM/QIO within five (5) calendar days of the election period, the effective date will be the date when the completed Form DOM 1166C is received. a) The Division of Medicaid will not reimburse the hospice or nursing facility providers for days prior to the effective date of the election statement. b) The hospice and/or nursing facility cannot seek payment from the beneficiary. 2. The UM/QIO will issue a prior authorization number once Form DOM 1166C is received to be notated on the claim by the hospice provider for nursing facility room and board reimbursement. 3. If the beneficiary elects the hospice benefit in a home setting, the UM/QIO will issue a prior authorization number once Form DOM 1166C is received. C. The Division of Medicaid may waive the consequences of failure to submit timely documentation for exceptional circumstances. 1. Exceptions to notice within five (5) calendar days: a) Fire, b) Floods, c) Embargoes, d) War, acts of war, insurrections, riots, e) Strikes, lockouts or other labor disturbances, f) Or acts of God. 2. A provider so affected shall use reasonable commercial efforts to avoid or remove such causes of nonperformance, and shall provide proper notice hereunder immediately whenever such causes are removed. Changes to the scope of available services or reimbursement methodology for the provision of certain services through legislative or regulatory action shall not constitute an unforeseeable circumstance within the meaning of this section.