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 updates to a previously submitted Form 3071 and to notify HHSC of updates to the person’s setting, location or status.
When to Prepare
The hospice provider must complete Form 3071 when:
- a person elects, cancels or updates hospice services.
- submitting a correction to a previously submitted Form 3071.
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 persons 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.
Retain Form 3071 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 Contractor, RULE Section 49.307-Record Retention and Disposition.
The hospice provider must maintain original signed and dated forms in the person’s hospice record.
1. Form Type — Mark the appropriate box:
- 1 = Election — Mark the box when a person elects the Medicaid hospice program. Examples include:
- election of Medicaid hospice by a person 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 diagnoses, location or status. Examples include:
- additional or change in terminal diagnosis;
- payment change;
- physician change;
- change in the setting or location where the person receives hospice services;
- person is admitted to a Skilled Nursing Facility (SNF) bed;
- person 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 to transfer the individual's information to the new provider.
- 3 = Cancel — Mark the box when a person cancels the Texas Medicaid Hospice Program. Examples include:
- a person voluntarily revokes hospice service;
- a person dies;
- a person no longer meets hospice eligibility requirements; or
- a person transfers to another service (including to another hospice provider).
2. 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 the person 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. This places the person in the initial 90-day election period.
If the person transfers from one hospice provider to another, the transferring provider enters cancel code 77. The receiving provider completes Form 3071, which begins a new initial 90-day election period. The receiving provider must follow all requirements in 26 TAC, Section 266.205, Election of Hospice Care.
3. From — Enter the date (MMDDYYYY) of the Medicaid hospice election, change in setting, location, or updates. Do not place a date if submitting a cancel form.
4. To — Enter the date (MMDDYYYY) hospice services are cancelled or the date the person died. Leave blank if submitting an election, re-election or update form.
5. Setting — Mark the box that indicates where the person resides: 1= Home, 2 = NF, 3 = Hospital, 4 = Hospice Inpatient Unit, 5 = ICF/IID, 6 = SNF.
6. Medicare Part A — Mark the box if the person has Medicare Part A.
7. Name of Individual (Last, First, Middle) — Enter the person’s name as it appears on the person’s Your Texas Benefits (YTB) Medicaid card.
8. 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.
9. Social Security No. — Enter the person’s Social Security number.
10. Date of Birth (MMDDYYYY) — Enter the person’s date of birth.
11. Name of Facility, Provider and Address of Individual (Street, City, State, ZIP) — Enter the address where the person receives hospice services.
12. Enter county of location – where hospice services will be provided. (www.census.gov)
13a - 16b. ICD Code — On line 13a, enter the principal terminal diagnosis, as stated by the certifying physician. Enter any additional pertinent, coexisting diagnoses related to the terminal condition on lines 14a-16a. If more lines are needed, enter additional diagnoses in the Enter Comments box (17). Lines 13b-16b.Enter an ICD code for each diagnosis. (Note: the terminal illness must be written out and include the ICD code)
17. Enter Comments — Examples of comments are located under 1. Form Type.
18. Hospice Name — Enter the doing business as (DBA) name of the Medicaid hospice provider as it appears on the HHSC Medicaid hospice contract.
19. Contract No. — Enter the nine-digit Medicaid hospice provider contract number as it appears on the HHSC Medicaid hospice contract.
20. Area Code and Phone No. — Enter the ten-digit phone number for the Medicaid hospice provider.
21. Hospice Address (Street, City, State, ZIP) — Enter the Medicaid hospice provider address as it appears on the HHSC Medicaid hospice contract.
22. Attending Physician's Name — Enter the name of the person’s attending physician if the person has an attending physician other than the hospice 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.
22. State License No. — Enter the attending physician's Texas state license number.
24. Enter the Date — the physician signed the person’s Form 3074, Physician Certification of Terminal Illness.
25. Printed Name of Hospice Representative — Enter the full name of the Medicaid hospice representative who must sign Form 3071 before submission on the TMHP LTC Online Portal.
26. Signature — Hospice Representative — The authorized hospice representative signs the form.
27. Date (MMDDYYYY) — The authorized hospice representative enters the date Form 3071 is signed.
28. 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, or 3 = Cancel (other than choosing to discharge) is the selected 1. Form Type.
29. Date (MMDDYYYY) — The individual or responsible party must enter the date Form 3071 is signed.