Form 3074, Physician Certification of Terminal Illness

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Documents

Effective Date: 1/2023

Instructions

Updated: 12/2022

Purpose

To certify a person’s terminal diagnosis and life expectancy of six months or less if the terminal illness runs its normal course, and to establish enrollment for the Medicaid hospice program.

Procedure

Disclaimer: This is a Texas Medicaid Hospice form. Providers may choose to use this form for people eligible for Medicare; however, to ensure accurate responses, Medicare hospice providers must contact the fiscal intermediary.

When to Prepare

  • When a person elects the Texas Medicaid Hospice program.
    • The hospice provider must obtain a written certification that meets requirements within two calendar days of the initial election.
    • If a hospice does not obtain the written certification within two days after an initial election period begins, the hospice must obtain an oral certification that meets the requirements no later than two days after the initial election period begins.
  • When a person is certified for the subsequent 90-day election period and each subsequent 60-day period.
    • For each election period after the initial election, the physician must sign and date the certification Form 3074 before the current certified election period ends but not more than 15 days before the election period being certified begins.
  • When corrections are made to a previously submitted Form 3074.
  • When a person transfers to another hospice. This will be treated as a new election and require a new Form 3074 for the initial 90-day period.

Important Reminders

  • The physician must sign all subsequent certifications not more than 15 days before the election period being certified begins.
  • An oral or written certification must include a physician’s narrative as stated in RULE Section 266.203 Certification of Terminal Illness (c)(2)(3).
  • The two-day allowance for a physician’s signature on the initial written certification does not apply to any subsequent election period.
  • The allowance of an oral verification of terminal illness in the initial election period does not apply to any subsequent recertification periods.
  • The physician may sign ‘within’ the election period only if it is the initial election period AND only if the oral certification is signed.
  • If a written certification is signed more than 2 days after the election period, the effective date for Medicaid payment will be the date of the physician’s signature, unless a valid oral certification is documented with 2 days of election.
  • If a person is discharged from hospice services for any reason and is then readmitted to hospice services, regardless of the amount of time, a new Form 3074 must be completed.

Transmittal

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 a person 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 this form according to the record retention requirements in Title 40 Texas Administrative Code (TAC), Part 1, Chapter 49, Contracting for Community Care Services, Subchapter C Requirements of a Contract, RULE Section 49.307-Record Retention and Disposition.

The hospice provider must maintain an original signed and dated form in the person’s hospice record.

Detailed Instructions

  1. Hospice Provider Name — Enter the doing business as (DBA) name of the Medicaid hospice provider as it appears on the HHSC Medicaid hospice contract.
  2. Contract No. — Enter the nine-digit Medicaid hospice provider contract number as it appears on the HHSC Medicaid hospice contract.
  3. Provider Address — Enter the Medicaid hospice provider address as it appears on the HHSC Medicaid hospice contract.
  4. Correction (check if applicable) — Mark the box when submitting a correction to a previously submitted Form 3074.
  5. Individual's Name (Last, First, Middle) — Enter the person’s name as it appears on the person’s Your Texas Benefits (YTB) Medicaid card.
  6. HHSC Medicaid No. — Enter the person’s Medicaid number as it appears on the person’s YTB Medicaid card. If the person has applied for, but is not yet receiving Medicaid benefits, enter "Pending" in the Medicaid number field.
  7. Medicare No. — Enter the person’s Medicare number, if applicable.
  8. Social Security No. — Enter the person’s Social Security number.
  9. Election or Start Date — Enter the hospice election date (MMDDYYYY) Note: If the person elects hospice on Jan. 1, 2014, and on June 30, 2014, the provider completes Form 3074 for recertification, the election date remains Jan. 1, 2014.
  10. Check Appropriate Box and Enter Date — Check the appropriate box and enter the current certification or recertification date (MMDDYYYY). For example, if the person elects hospice on Jan. 1, 2014, and the certification date is Jan. 1, 2014, the physician(s) must sign the certification by June 30, 2014. If the recertification date begins July 1, 2014, then the physician must sign by Dec. 31, 2014.
  11. Individual's Address — Enter the address where the person receives hospice services.
  12. Signature — Hospice Staff — Hospice staff must sign the oral verification statement when oral verification has been verified in the person’s record for the initial election; if no oral certification is made, the physician must sign the certification within two days of the initial hospice election date.
  13. Date Signed — The hospice staff must enter the date (MMDDYYYY) the oral verification statement is signed.
  14. Print Name of Attending Physician (Last, First) — Print the physician's name.
  15. Signature — Attending Physician — The attending physician must sign Form 3074 within the applicable certification or recertification time frame.
  16. Check Appropriate Box and Enter Number — The physician must indicate if this is a State of Texas License No. or Military Spec. Code No. by checking the appropriate box. A licensed physician in the state of Texas or a physician on duty with the U.S. military must enter his or her license number (one letter and four digits) or a military specialty code next to the applicable box.
  17. Date Signed — The physician must enter the date (MMDDYYYY) he or she signed Form 3074.
  18. Print Name of Hospice Physician (Last, First) — Print the hospice physician's name.
  19. Signature — Hospice Physician — The hospice physician must sign Form 3074. If the person receiving services has an attending physician, the attending and hospice physicians must sign the initial certification statement. If the person does not have an attending physician, the hospice physician will provide the only certification signature. These signatures must meet the 90-90-60-day certification or recertification time requirements.
  20. Check Appropriate Box and Enter Number — The physician must indicate if this is a State of Texas License No. or Military Spec. Code No. by checking the appropriate box. A licensed physician in the state of Texas or a physician on duty with the U.S. military must enter his or her license number (one letter and four digits) or a military specialty code next to the applicable box.
  21. Date Signed — The physician must enter the date (MMDDYYYY) he or she signed the form. The physician(s) who sign and date Form 3074 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 box number 20 if the physician is on duty military. If the attending physician is a resident or holds a temporary license, the supervising physician must complete, sign and date this form.
  22. Signature — Hospice Staff — A member of the hospice staff must sign the exclusion statement if the person does not have an attending physician separate from the hospice physician.
  23. Date Signed — The hospice staff must enter the date (MMDDYYYY) he or she signed the exclusion statement.