Form 3071, Individual Election/Cancellation/Update

Effective Date: 9/2014

Availability

English PDF: 3071.pdf

Spanish PDF: 3071-S.pdf

Instructions

Updated: 9/2014

Purpose

Use Form 3071 to notify the Department of Aging and Disability Services (DADS) 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 DADS of updates to an individual’s setting, location or status.

Procedure

Supply Source

www.DADS.state.tx.us/forms/3071.

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

  1. 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 DADS 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. 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).
  1. Cancel Code — Enter the appropriate code when the cancel box is checked:

13 – Individual denied Medicaid
14 – Individual transferred to another service other than hospice
16 – Individual not certified for hospice by a physician
18 – Individual refused to follow plan of care
19 – Unsafe environment for hospice staff
75 – Individual died
76 – Individual moved out of the hospice provider service area or cannot be located
77 – Individual transferred to another hospice, withdrew, was dissatisfied or refused service

Note: If an individual cancels hospice for any reason and then is readmitted to hospice, regardless of the amount of time between election periods, a new Form 3071 and a new Form 3074, Physician Certification of Terminal Illness, must be completed.

If an individual transfers from one hospice provider to another, the transferring provider enters cancel code 77. The receiving provider completes Form 3071, begins a new service authorization period, and must follow all requirements in 30 TAC, §30.16, Election of Hospice Care.

  1. From — Enter the date (MMDDYYYY) of the Medicaid hospice election or hospice individual’s setting, location or condition update. Leave this box blank if submitting a cancel form.

  2. To — Enter the date (MMDDYYYY) hospice services are cancelled or the date the individual died. Leave blank if submitting an election or update form.

  3. Setting — Mark the box that indicates where the individual resides: 1= Home, 2 = NF, 3 = Hospital, 4 = Hospice Inpatient Unit, 5 = ICF/IID, 6 = SNF.

  4. Medicare Part A — Mark the box if the individual has Medicare Part A.

  5. Name of Individual (Last, First, Middle) — Enter the individual’s name as it appears on the individual’s Your Texas Benefits (YTB) Medicaid card.

  6. Medicaid No. — Enter the individual's Medicaid number as it appears on the individual’s YTB Medicaid card. If the individual has applied for, but is not yet receiving Medicaid benefits, enter "Pending" in the Medicaid number field.

  7. Social Security No. — Enter the individual's Social Security number.

  8. Date of Birth (MMDDYYYY) — Enter the individual’s date of birth.

  9. Name of Facility/Provider and Address of Individual (Street, City, State, ZIP) — Enter the address where the individual receives hospice services.

  10. www.census.gov.

  11. 13-16. ICD Code — On line 13, enter the principal terminal diagnosis, as stated by the certifying physician. Enter any additional pertinent, coexisting diagnoses related to the terminal condition on lines 14-16. If more lines are needed, enter additional diagnoses in the Enter Comments box (17). Enter an ICD code for each diagnosis.
  1. Enter Comments — Examples of comments are located under 1. Form Type.

  2. Hospice Name — Enter the doing business as (DBA) name of the Medicaid hospice provider as it appears on the DADS Medicaid hospice contract.

  3. Contract No. — Enter the nine-digit Medicaid hospice provider contract number as it appears on the DADS Medicaid hospice contract.

  4. Area Code and Telephone No. — Enter the ten-digit phone number for the Medicaid hospice provider.

  5. Hospice Address (Street, City, State, ZIP) — Enter the Medicaid hospice provider address as it appears on the DADS Medicaid hospice contract.

  6. Attending Physician's Name — Enter the name of the individual’s attending physician. The attending physician identified on Form 3071 must hold a current active physician’s license in the state of Texas, or be on duty with the U.S. military. Enter a military specialty code in the license number field if the physician is on military duty. If the attending physician is a resident or holds a temporary license, the supervising physician must complete, sign and date this form.

  7. State License No. — Enter the attending physician's Texas state license number.

  8. Date of Orders (MMDDYYYY) — Enter the date the physician signed the individual's Form 3074, Physician Certification of Terminal Illness.

  9. Printed Name of Hospice Provider Representative — Enter the full name of the Medicaid hospice provider representative who must sign Form 3071 before submission on the TMHP LTC Online Portal.

  10. Signature – Hospice Representative — The authorized hospice provider representative signs the form.

  11. Date (MMDDYYYY) — The authorized hospice provider representative enters the date Form 3071 is signed.

  12. Signature — Individual — The hospice individual or responsible party, acting pursuant to state law, must sign Form 3071 to elect the Medicaid hospice program. The original signature of the individual or responsible party is required.

    Marking "Signature on File” is unacceptable and will make the form invalid.

    The individual or responsible party must sign Form 3071 when 1 = Election is selected in 1. Form Type, and when the individual or responsible party choose to discharge (cancel code 77) out of hospice. The individual or responsible party is not required to sign Form 3071 when 2 = Update, 3 = Correction or 4 = Cancel (other than choosing to discharge) is the selected 1. Form Type.
  1. Date (MMDDYYYY) — The individual or responsible party must enter the date Form 3071is signed.
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