Hospice Program

Forms and Certifications

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This training program will focus on the

required forms for the MO HealthNet

Hospice Program as well the required due

dates for each form. In addition,

information on initial certification and

recertifications will be provided.

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Hospice Forms

Physician Certification of Terminal Illness

Hospice Election Statement Hospice – Nursing Facility Contract

Update Notification of Termination of Hospice

Benefits

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Hospice Forms cont.Hospice forms can be obtained on the MO HealthNet Division (MHD) Web site,

http://www.dss.mo.gov/mhd/providers/index.htm

All forms can be faxed to the Hospice Unit at (573) 526-2041. Please do not mail forms that have been faxed. Make certain all formssent, faxed or mailed, are legible.

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Submission of Forms

It is the responsibility of the hospice to submit all documentation in a timely manner. Reimbursement of hospice claims is dependent on receipt of correctly completed documentation.If accurate documentation is not submitted toMHD timely, hospice claims will deny. Late submissions can cause denial of services to participants, denial and/or incorrect paymentsto providers.

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Physician Certification of Terminal Illness

The hospice agency must obtain physician

certification an individual is terminally ill. The

Certification of Terminal Illness must include: statement the individual’s medical prognosis is

a life expectancy of six (6) months or less, contain the physician’s signature(s), and be dated by the physician(s) within two (2)

calendar days after hospice care is initiated.

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Physician Certification cont.

If the hospice does not obtain a completed Physician Certification of Terminal Illness within two days after the initiation of hospice care, a verbalcertification may be obtained within these two days and written certificationobtained at a later date.

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The Hospice Election Statement

An election statement must be submitted for: each MO HealthNet participant electing the

hospice benefit; simultaneous election for those with dual

Medicare/MO HealthNet coverage; and, individuals receiving hospice services as a

private pay client who later becomes

eligible for MO HealthNet.

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Election Statement cont.

The participant’s hospice election date for

which services may be reimbursed by MHD

is no earlier than the first date of MO

HealthNet eligibility. The Hospice Election

Statement is due within five (5) days of

execution.

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RecertificationsFor each subsequent election period, the hospice must obtain no later than two calendardays, a signed and dated Physician Certificationof Terminal Illness. MHD follows Medicare election periods of 90-90-60 days followed byan unlimited number of 60-day periods. Therecertifications for these election periods are due to MHD within five (5) days of the recertification due date.

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Hospice-Nursing Facility Contracts

The Hospice-Nursing Facility Contracts formis used by the hospice to notify MHD of eachnursing facility the hospice has a contract with. This form must be completed by the hospice agency and submitted to the MHD Hospice Unit before nursing home room andboard payments can be made to the hospice.

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Hospice-NursingFacility Contracts cont.

The hospice and the nursing facility must

retain a copy of the contract; a copy of the

contract is not to be sent to MHD. The

hospice must also have on file a copy of an

IM-62 form for each nursing home resident,

obtained either from the participant, the

participant’s family and/or representative or

the nursing home.

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Notification of Termination of Hospice Benefits

The participant or participant’s representative

may revoke the hospice benefit at any time by

filing a Notification of Termination of Hospice

Benefits form. The effective date of the

revocation is the date of the participant’s or

participant’s representative’s signature unless a

subsequent date is designated. A designated

effective date earlier than the date the revocation

is signed is unacceptable.

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Notification of Termination of Hospice Benefits cont.

The Notification of Termination of Hospice

Benefits form is due at MHD within five (5)

days for the following: Revocation by patient choice; Change of designated hospice provider; Decertification of terminal illness by physician; Discharge due to patient relocation; or Death of patient while on hospice service.

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Reference Materials

Additional information regarding the MO

HealthNet Hospice Program can be found in

the hospice provider manual, section 13 located

on the MHD Web site:

http://www.dss.mo.gov/mhd/providers/index.htm

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Thank you for participating in this

training program. If you have

questions regarding the information

contained in this presentation,

please contact the Provider

Education Unit at 573-751-6683.