Texas Medicaid Hospice Program Form 3074
Instructions Updated: 9/2014 Purpose Use Form 3071 to notify the Texas Health and Human Service Commission (HHSC) of an individual's election or cancellation of the Texas Medicaid Hospice Program, to make corrections to a previously submitted Form 3071 and to notify HHSC of updates to an individual’s setting, location or status. Procedure When to Prepare The hospice provider must complete Form 3071 when:. an individual elects, cancels or updates hospice services. submitting a correction to a previously submitted Form 3071. Transmittal Hospice providers are responsible for transmitting Form 3071 electronically on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal. Hospice providers must send a copy of this form to the nursing facility (NF) or the intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), if applicable.
To set up an account to submit electronic forms, contact TMHP Electronic Data Interchange (EDI) at 1-800-626-4117, option 3. To speak with TMHP customer service for assistance with navigating the TMHP LTC Online Portal, contact TMHP at 1-800-626-4117, option 1.
Form Retention Retain Form 3071 according to the record retention requirements in 40 Texas Administrative Code (TAC), Chapter 49, Contracting for Community Care Services. The hospice provider must maintain original signed and dated forms in the individual's hospice record. Detailed Instructions. Form Type — Mark the appropriate box: 1 = Election — Mark the box when an individual elects the Medicaid hospice program. Examples:. Election of Medicaid hospice by an individual for the first time;. Subsequent re-election; and.
Transfer from one hospice provider to another.In this instance, the receiving provider submits this form and marks 'elect.' 2 = Update — Mark the box when there is a change to the individual's condition, location or status. Examples:. Additional terminal diagnoses;. Payment change;. Physician change;.
Change in the setting/location where the individual receives hospice services;. Individual is admitted to a Skilled Nursing Facility (SNF) bed;. Individual is admitted back to an NF; and. Change of ownership (CHOW) of the hospice provider that results in a new HHSC contract number. This update is required in order to transfer the individual's information to the new provider. 3 = Correction — Mark the box when submitting a correction to a previously submitted Form 3071. Mark only the fields that require correction.
All fields are correctable except the contract number. 4 = Cancel — Mark the box when an individual cancels the Texas Medicaid Hospice Program.
Texas Medicaid Hospice Providers
Examples:. An individual voluntarily revokes hospice service;.
An individual dies;. An individual no longer meets hospice eligibility requirements; and. An individual transfers to another service (including to another hospice provider).