Hospice providers are responsible for transmitting Form 3074 electronically on the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Online Portal. Hospice providers must send a copy of Form 3074 to the nursing facility (NF) or the intermediate care facility for individuals with an intellectual disability or related conditions.

.Revision 11-1; Effective May 11, 20114100 General InformationRevision 11-1; Effective May 11, 2011A provider must have a DADS Medicaid contract to receive Medicaid payment for hospice services. DADS pays the Medicaid hospice provider at periodic intervals, depending on when the provider bills for approved services.

Payments are based on the hospice care setting applicable to the type and intensity of hospice services provided to the Medicaid hospice recipient for that day.DADS Provider Claims Services authorizes hospice services, according to department, state and federal regulations, for contracted providers that furnish Medicaid services to DADS consumers. Provider Claims Services does not develop program policy, but is responsible for applying established policy when performing the authorization for reimbursement function.Payment for hospice services is controlled by receipt of information.

. (a) The Resource Utilization Group (RUG-III) 34-group classification system has seven major classification groups. The groups represent the recipient's relative direct care resource requirements. (b) The Activities of Daily Living (ADL) score is based on the recipient's care needs that are provided by the nursing facility staff. The ADL score is used to determine a recipient's placement in a RUG-III category and is based on the recipient's care needs provided by the nursing facility staff. The score is incorporated into acuity measurements established under the RUG-III recipient classification methodology.

The clinical record must support items claimed for Medicaid reimbursement on the Minimum Data Set (MDS). (c) The state-specific Long-Term Care Medicaid Information Section is a part of the MDS assessment Resident Assessment Instrument (RAI) in Texas and must be completed for Medicaid reimbursement. The Long-Term Care Medicaid Information Section must include the last name and license number of the registered nurse (RN) assessment coordinator. (d) The Basic Tracking Form must include: (1) the signature and title of each licensed nurse or health care professional completing any section of the MDS assessment for Medicaid reimbursement; and (2) the section(s) and completion date(s) corresponding to the signature of the nurse or health care professional. (e) Each individual signing the signature section on the Basic Tracking Form is certifying that the information entered on the MDS assessment is accurate.

A facility that submits false or inaccurate information is subject to sanctions under Subchapter G of this chapter (relating to Administrative Actions and Sanctions). (f) If the nursing facility recipient is a hospice recipient, the nursing facility must comply with the requirements of 40 TAC §19.1926 (relating to Medicaid Hospice Services) and maintain in the recipient's clinical record copies of the completed Texas Medicaid Hospice Program Recipient Election/Cancellation/Discharge Notice (Form 3071), and the DADS Medicaid/Medicare Hospice Program Physician Certification of Terminal Illness (Form 3074). (1) The nursing facility must acknowledge a recipient's admission to hospice services on the Special Treatments, Procedures, and Programs section when completing an MDS full, comprehensive, or quarterly assessment. (2) An MDS assessment indicating that a recipient has elected hospice services is not processed until the Texas Medicaid Hospice Program Recipient Election/Cancellation/Discharge Notice (Form 3071), and the DADS Medicaid/Medicare Hospice Program Physician Certification of Terminal Illness (Form 3074) are received by the Texas Medicaid Claims Administrator.

(3) When a recipient is admitted to hospice and there has not been a significant change in condition, a significant change in status assessment does not have to be completed. The recipient's next scheduled assessment may be used. (g) Each nurse's license number submitted on the MDS assessment, Long-Term Care Medicaid Information Section, is validated with the Texas Board of Nursing or as applicable as a nurse compact license with the licensing state. An MDS assessment is rejected for Medicaid reimbursement if an invalid or delinquent license number is submitted on the MDS assessment, Long-Term Care Medicaid Information Section.

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(h) Nursing facility staff must complete the HHSC-approved MDS training in accordance with this subsection. (1) The nursing facility RN Assessment Coordinator must complete the HHSC-approved online MDS training course prior to completing an MDS assessment for Medicaid payment. All other staff completing the MDS assessment for Medicaid payment are encouraged to take the MDS Training prior to completing the MDS assessment.

(2) The nursing facility RN Assessment Coordinator must repeat the MDS online training every two years. A certificate of completion is issued at the conclusion of the training.

(3) If the nursing facility RN Assessment Coordinator does not complete the MDS training every two years as required by HHSC, the license number of the RN Assessment Coordinator is not accepted into the state database and the MDS assessment is rejected by the Medicaid claims administrator. (i) An admission assessment, a quarterly assessment, significant change in status assessment, annual assessment, significant correction to a prior quarterly assessment, or a significant correction to a prior annual assessment establishes a RUG-III group.

(1) A significant change in status assessment, which requires a comprehensive MDS with Resident Assessment Protocols, must be completed by the end of the 14th calendar day following determination that a significant change has occurred. (2) A significant change in status assessment resets the schedule for the next annual assessment.

(j) Permanent medical necessity is determined by DADS in accordance with 40 TAC §19.2403 (relating to Medical Necessity Determination). (k) When correcting errors in an MDS assessment, the nursing facility staff must use the MDS Correction Policy in Chapter 5 of the Minimum Data Set, Resident Assessment Instrument User's Manual, published by CMS. (1) Documentation must be maintained in the clinical record to support the corrected MDS assessment form and be available for review by the OIG staff during MDS utilization reviews. (2) The Correction Request Form attestation of accuracy of signatures must contain the RN assessment coordinator's and Director of Nursing's signatures, and the date the correction was completed. (3) A correction to a RUG reclassification error identified during an on-site review is considered an assessment error as described in subsection (r)(2) of this section. This does not negate the facility's responsibility to make quality of care corrections pursuant to the CMS MDS Correction Policy referenced in this section.

(l) The MDS assessment establishes the rate(s) at which the Texas Medicaid program pays a nursing facility or hospice provider for the facility's hospice residents to support the care the nursing facility's residents receive and any information on the MDS RAI is considered part of each corresponding claim for Medicaid reimbursement. (m) Prior to entering a nursing facility for review, the OIG identifies a population of paid claims from which a sample is drawn.

(1) The population is defined as claims associated with RUG classifications: (A) paid to the nursing facility, or hospice provider for the facility's hospice residents, for a specified time period; and (B) that meet certain criteria, such as dollar or claim volume, as determined by the OIG. (2) The OIG identifies the population of paid claims, along with their related RUG classifications and MDS assessment claim forms, from which a statistically valid random sample is drawn for review.

The sample generated is a statistically valid random sample generated at a minimum confidence level of 90 percent and a maximum precision of ten percent. Related extrapolations are done at the lower limit of the applicable confidence interval. (n) Utilization reviews are conducted in accordance with this subsection.

(1) OIG nurse reviewers conduct unannounced on-site MDS utilization reviews of nursing facilities.