The Nevada FA 27 form is a notification tool for hospice agencies to inform HP Enterprise Services about the enrollment, changes, or recertification of hospice recipients. Timely submission is crucial, as the form must be faxed within 72 hours of any updates. Ensure you include all required attachments to avoid delays in processing.
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HP Enterprise Services - Nevada Medicaid and Nevada Check Up
Hospice Notification Form
Purpose: For a hospice agency to notify HP Enterprise Services of any hospice recipient enrollment, GLVFKDUJH change or recertification. Fax this form to HP Enterprise Services within 72 hours of new or FKDQJHG LQIRUPDWLRQ
Attachments: These attachments must be submitted with this form: 1) certificate of terminal illness,
2)election of hospice services and 3) updated physician orders for recertification. If the recipient is residing or will reside in a Nursing Facility, a PASRR screening and LOC Determination Letter must be attached in addition to the documents listed above.
Fax this form to: (866) 480-9903
For questions regarding this form, call:
(800) 525-2395
SUBMISSION DATE (date this form is submitted):
HOSPICE AGENCY INFORMATION
Name:
NPI:
Address:
Phone:
Fax:
PHYSICIAN INFORMATION
Attending Provider Name:
Hospice Physician Name:
RECIPIENT INFORMATION
Recipient Name (last, first, MI):
Address (include city, state and zip):
Recipient ID:
Medicare ID (if applicable):
Date of Birth:
Sex:
Male
Female
Marital Status:
Single
Married
Divorced
Widowed
List the names of all of all other payors (if
applicable):
NOTIFICATIONS AND CLINICAL INFORMATION
Hospice Diagnosis:
ICD-9 Code(s):
Hospice Enrollment Date:
Recertification Date:
Certification Period:
1st 90 days
2nd 90 days
60 days
Revocation Date (hospice disenrollment):
Transfer Date to New Facility:
Date of Discharge to Home, on Hospice:
Date of Death:
Is the recipient currently residing in a Nursing Facility?
No
Yes – If yes, complete next section.
Other Services Currently Provided:
Personal Care Services (PCS)
Waiver Services
None
If PCS or waiver services are being provided, you must submit a completed Form FA-24A, "Care Coordination
for Hospice and PCS or Waiver Services."
NURSING FACILITY INFORMATION (Required if recipient currently resides in a Nursing Facility.)
Is the recipient residing in a Medicaid bed?
Yes
SUBMITTER INFORMATION
Signature of Person Completing this Form:
Date:
FA-27
Page 1 of 1
0/01/11
Filling out the Nevada Fa 27 form requires careful attention to detail. This form must be submitted to HP Enterprise Services within 72 hours of any changes related to hospice enrollment. After completing the form, it should be faxed to the designated number. Ensure that all required attachments are included for a smooth submission process.
After filling out the form, ensure that you have attached the necessary documents: the certificate of terminal illness, election of hospice services, and updated physician orders for recertification. If the recipient is in a nursing facility, include the PASRR screening and LOC determination letter as well. Finally, fax the completed form to (866) 480-9903.
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What is the purpose of the Nevada Fa 27 form?
The Nevada Fa 27 form is designed for hospice agencies to notify HP Enterprise Services about any changes related to hospice recipients. This includes enrollment, changes in status, or recertification. It ensures that the necessary information is communicated promptly and accurately.
What attachments are required when submitting the Fa 27 form?
When submitting the Fa 27 form, several attachments are required. These include a certificate of terminal illness, an election of hospice services, and updated physician orders for recertification. If the recipient is in a Nursing Facility, additional documents like a PASRR screening and a LOC Determination Letter must also be included.
How quickly must the Fa 27 form be submitted?
The Fa 27 form must be faxed to HP Enterprise Services within 72 hours of any new enrollment or change in information regarding the hospice recipient. Timely submission is crucial to ensure that the recipient continues to receive appropriate care and services.
What information is needed about the hospice agency and the recipient?
The form requires detailed information about both the hospice agency and the recipient. For the hospice agency, you need to provide the name, NPI, address, phone, and fax number. For the recipient, you must include their name, address, recipient ID, Medicare ID (if applicable), date of birth, sex, and marital status, among other details.
Who should I contact if I have questions about the Fa 27 form?
If you have questions regarding the Fa 27 form, you can call HP Enterprise Services at (800) 525-2395. They can provide guidance and clarify any uncertainties you may have about the form or the submission process.
Incomplete Information: One of the most common mistakes is failing to provide all required details. This includes missing the recipient's full name, address, or date of birth. Each section must be filled out completely to avoid delays.
Missing Attachments: Not including necessary documents can lead to rejection of the form. Ensure that you attach the certificate of terminal illness, election of hospice services, and updated physician orders for recertification. If applicable, include the PASRR screening and LOC Determination Letter.
Incorrect Submission Method: Submitting the form via the wrong fax number can cause significant delays. Always double-check that you are faxing to (866) 480-9903. This ensures your submission reaches the right department promptly.
Failure to Update Information: If there are any changes in the recipient's status, such as a transfer to a new facility or changes in payors, these must be updated on the form. Neglecting to do so can result in complications with service provision.
When dealing with the Nevada FA 27 form, several other documents and forms may be necessary to ensure a smooth process. Each of these plays a critical role in the overall care and administrative requirements associated with hospice services. Here’s a brief overview of those documents.
Each of these forms plays a vital role in ensuring that patients receive the appropriate care and that all necessary procedures are followed. Having them ready can help streamline the process and provide peace of mind for everyone involved.