Hospice 5-day notification requirements and completion of HCA 13-746 form

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Apple Health (Medicaid) Provider Alert

What is changing?

There is no change to the agency’s current process for hospice 5-day notification for Washington Apple Health (Medicaid) clients. 

When does the agency require a completed hospice 5-day notification?

The agency requires a completed hospice 5-day notification form (HCA/Medicaid Hospice Notification, HCA 13-746) when the client is enrolled in hospice and resides in a nursing home, or may be admitted to a nursing home, and is one of the following: 

  • A Medicare client whose Medicaid eligibility is pending or who has not yet applied for Medicaid; or
  • A dual-eligible client (currently enrolled in Medicare and Medicaid). 

Please review the HCA/Medicaid Hospice Notification (HCA 13-746) form for complete and valid information, including current attending physician. The agency will return incomplete or incorrect forms by fax. To download an agency provider form, go to HCA’s Billers and provider’s web page, select Forms & publications.

When does the agency NOT require a completed hospice 5-day notification? 

Do not send an HCA/Medicaid Hospice Notification form to the agency for anyone who is private pay and not enrolled in Washington Apple Health (Medicaid).