Hospice Program Forms and Certifications 1

2 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.

3 Hospice Forms Physician Certification of Terminal Illness Hospice Election Statement Hospice – Nursing Facility Contract Update Notification of Termination of Hospice Benefits

4 Hospice Forms cont. Hospice forms can be obtained on the MO HealthNet Division (MHD) Web site, All forms can be faxed to the Hospice Unit at (573) Please do not mail forms that have been faxed. Make certain all forms sent, faxed or mailed, are legible.

5 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 to MHD timely, hospice claims will deny. Late submissions can cause denial of services to participants, denial and/or incorrect payments to providers.

6 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 individuals medical prognosis is a life expectancy of six (6) months or less, contain the physicians signature(s), and be dated by the physician(s) within two (2) calendar days after hospice care is initiated.

7 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 verbal certification may be obtained within these two days and written certification obtained at a later date.

8 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.

9 Election Statement cont. The participants 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.

10 Recertifications For each subsequent election period, the hospice must obtain no later than two calendar days, a signed and dated Physician Certification of Terminal Illness. MHD follows Medicare election periods of days followed by an unlimited number of 60-day periods. The recertifications for these election periods are due to MHD within five (5) days of the recertification due date.

11 Hospice-Nursing Facility Contracts The Hospice-Nursing Facility Contracts form is used by the hospice to notify MHD of each nursing 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 and board payments can be made to the hospice.

12 Hospice-Nursing Facility 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 participants family and/or representative or the nursing home.

13 Notification of Termination of Hospice Benefits The participant or participants 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 participants or participants representatives signature unless a subsequent date is designated. A designated effective date earlier than the date the revocation is signed is unacceptable.

14 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.

15 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:

16 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