FORMS
TRANSFERS POTENTIAL FINANCIAL LIABILITY TO THE MEDICARE BENEFICIARY
WHAT IS THE ADVANCED BENEFICIARY NOTICE (ABN)?
BENEFICIARY WISHES TO TERMINATE HOSPICE CARE AND RETURN TO REGULAR MEDICARE COVERAGE
WHAT IS REVOCATION?
THE DC TYPE WHEN A F2F IS NOT OBTAINED PER REGULATORY REQUIREMENT.
WHAT IS A LIVE DC FOR BEING MEDICALLY INELIGIBLE?
INFORMS THE BENEFICIARY OF ANY ITEMS, SERVICES, OR DRUGS THE HOSPICE WILL NOT COVER
WHAT IS THE HOSPICE ELECTION STATEMENT ADDENDUM (EOB ADDENDUM)?
DESIGNATED BY THE PATIENT; THERE CANNOT BE A GAP-MUST OCCUR SAME DAY.
WHAT IS A HOSPICE TRANSFER?
THE DC TYPE(S) THAT REQUIRE MD ORDER.
WHAT IS LIVE DC FOR MEDICALLY INELLIGIBLE, OUT OF SERVICE AREA, AND DC FOR CAUSE?
FOR THE DURATION OF THE ELECTION OF HOSPICE CARE, AN INDIVIDUAL WAIVES ALL RIGHTS TO MEDICARE PAYMENTS FOR ANY MEDICARE SERVICES THAT ARE RELATED TO THE TREATMENT OF THE TERMINAL CONDITION FOR WHICH HOSPICE CARE WAS ELECTED
WHAT IS THE WAIVER OF OTHER BENEFITS ON THE ELECTION STATEMENT?
42 CFR 418.24(g)
ALLOWED ONCE PER BENEFIT PERIOD
WHAT IS A TRANSFER?
THE DC TYPE THAT SHOULD BE REPORTED TO THE STATE.
WHAT IS A DC FOR CAUSE?
ALLOWS THE BENEFICIARY TO APPEAL THE PROVIDER'S DECISION TO TERMINATE SERVICE, RECEIVE A RAPID DETERMINATION, AND BE PROTECTED FROM FINANCIAL LIABILITY DURING THE PROCESS
WHAT IS THE NOTICE OF MEDICARE NON-COVERAGE (NOMNC)?
THE DATE THE FORM IS SIGNED OR A LATER DATE; MAY NOT BE AN EARLIER DATE
WHAT IS THE REVOCATION EFFECTIVE DATE?
THE ABN, NOMNC, AN DENC SHOULD BE PROVIDED FOR THIS DC TYPE.
WHAT IS A LIVE DC FOR BEING MEDICALLY INELIGIBLE?
GIVES A SPECIFIC DETAILED EXPLANATION OF WHY SERVICES ARE NO LONGER COVERED
WHAT IS THE DETAILED EXPLANATION OF NON-COVERAGE (DENC)?
NO PHYISIAN ORDER REQUIRED
WHAT IS A PATIENT INITIATED LIVE DC?
(REVOCATION AND TRANSFER)
THE DC TYPE FOR A PATIENT THAT GOES TO A NON-CONTRACTED FACILITY.
WHAT IS A DC OUT OF SERVICE AREA?