File name: Hospice Revocation Form Pdf
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The Notice of Termination/Revocation (NOTR), Type of Bill (TOB) 8XB, is submitted when the hospice discharges the beneficiary or the beneficiary chooses to revoke the Medicare Hospice . Hospice providers must notify the Division of Medicaid's UM/QIO within five (5) calendar days after the hospice revocation and discharge date for Medicaid only beneficiaries. CMS commented on revocation in the FY Hospice Wage Index proposed rule by saying “nor is it appropriate for hospices to encourage, request, or demand that the beneficiary or his or . Revocation of the Medicare Hospice Benefit • A patient or representative may revoke the election of hospice care at any time in writing; a hospice cannot “revoke” a patient’s election. • Documentation required: o The patient or representative must file a document with the hospice that includes. The beneficiary has revoked the hospice benefit. (Complete the revocation statement below) The beneficiary has transferred to another hospice provider. Beneficiary Revocation Statement: a) The Medicaid Hospice Program has been explained to me. I have been given the opportunity to discuss the services, benefits requirements and limitations of this program and the terms of the revocation of these services.
